Monday 4 June 2018

Tutorial 4th. June 2018


4 June  2018

14
EMQ. Surrogacy EMQ. Surrogacy
15
EMQ. Pregnancy after renal transplant
16
EMQ. Abortion Act
17
EMQ. Anatomy of fetal skull and maternal pelvis
18
EMQ. Anti-Müllerian hormone

14.   EMQ. Surrogacy.
Surrogacy.
Lead-in.
This question is about surrogacy. For each scenario, pick the best choice from the option list. Each option can be used once, more than once or not at all.
Abbreviations.
CF:              commissioning father
CM:            commissioning mother
CPs:            commissioning parents
PO:             parental order
SM:             surrogate mother
Option List.
a)      CM
b)      CF
c)       CPs
d)      SM
e)      Chairman of the HFEA
f)        Senior judge at the Children and Family Court
g)       traditional surrogacy
h)      gestational surrogacy
i)        HFEA
j)        SSAEW
k)       RCOG Surrogacy Sub-Committee
l)        false
m)    true
n)      none of the above
Scenario 1
List the different types of surrogacy.
Scenario 2.
“Gestational” surrogacy has better “take-home-baby” rates than “traditional” surrogacy.
Scenario 3
There are approximately 1,000 surrogate pregnancies per annum in the UK. True/False
Scenario 4.
Which national body regulates surrogacy in England?
Scenario 5.
Privately-arranged surrogate pregnancies are illegal and those involved are liable to up to 2 years in prison. True/False
Scenario 6.
List the risks of surrogacy.
Scenario 7.
Obstetricians are legally obliged to take the CPs’ wishes into consideration in managing pregnancy complications or problems.
Scenario 8.
The psychological outcomes of surrogacy are fully understood. True/False.
Scenario 9.
The psychological outcomes of surrogacy are more severe after traditional surrogacy. True/False
Scenario 10.
Who has the right to arrange TOP if the fetus is found to have a major congenital abnormality?
Scenario 11.
A SM decides at 10 weeks that she does not wish to be pregnant and arranges to have a TOP. The CPs. hear about this and object strongly. To whom should they apply to have the TOP blocked?
Scenario 12.
A woman has hysterectomy and BSO to deal with extensive endometriosis at the age of 30. She marries two years later and her sister offers to act as surrogate. She undergoes IVF and 4 embryos are created. One is transferred and a successful pregnancy ensues. The baby is adopted by the woman and her husband. The 3 remaining embryos were frozen. Four years later the woman falls out with her sister, but finds another surrogate and wishes to proceed with another pregnancy. The sister says she does not want her eggs to be used and that the frozen embryos should not be transferred. Does the sister have the legal right to block the use of the embryos? Yes / No.
Scenario 13.
A girl born from donor sperm reaches the age of 16 and wishes to know the identity of her genetic father. Does she have the right to this information?  Yes / No.
Scenario 14.
A girl born from donor sperm reaches the age of 18 and wins a place at Oxford University to read medicine. Does she have the legal right to get the donor to contribute to her fees? Yes / No.
Scenario 15.
A PO is active from the moment it is completed and signed by the relevant parties.  True/False
Scenario 16.
A SM can change her mind at any time and keep the child, even if the egg was not hers.  True/False
Scenario 17.
The CPs can change their mind, leaving the SM as the legal mother.  True/False
Scenario 18.
A SM’s husband is the legal father until adoption is completed or a PO comes into force.
Scenario 19.
A lesbian couple in a stable, co-habiting relationship can be CPs and become the legal parents of the child of a SM.
Scenario 20.
CPs are likely to get faster legal status as the legal parents through application for a PO rather than applying for adoption.

15.   EMQ. Pregnancy after renal transplant.
Abbreviations.
AZP:      azathioprine
CCSs:     corticosteroid
eGFR:    estimated glomerular filtration rate
GFR:      glomerular filtration rate
MMF:    mycophenolate mofetil
RT:         renal transplant
TCL:       tacrolimus
Question 1
Approximately how many women who have had renal transplant have pregnancies annually in the UK?
Option list.
A
10-20
B
30-40
C
50-100
D
100-200
E
200-300
F
300-400
G
400-500
H
>500
Question 2
Which, if any, of the following statements are true about the findings of the UKOSS survey of renal transplant in pregnancy?
Option list.
A
the incidence of PET was ~ 25%, roughly six times higher than the general population
B
the incidence of PET was ~ 25%, roughly ten times higher than the general population
C
the incidence of PET was ~ 50%, roughly ten times higher than the general population
D
the incidence of PET was ~ 50%, roughly twenty times higher than the general population
E
none of the above
Question 3
Various sources, such as AST, give factors linked to reduced risks associated with pregnancy after RT. A lot of this is common sense. Write down all the factors that would be in your list.
Question 4
What is the risk of graft rejection in the year after RT?
Option list.
A
< 5%
B
10-15%
C
15-20%
D
20-25%
E
unknown
Question 5
Which of the following factors are the 3 main ones affecting pregnancy outcome?
Factors
1
anaemia
2
diabetes
3
hypertension
4
number of immunosuppressive drugs being used
5
obesity
6
pre-pregnancy graft function
7
proteinuria
8
urinary tract infection
Option list.
A
1 + 2 + 3
B
1 + 2 + 6
C
2 + 3 + 4
D
2 + 4 + 6
E
3 + 6 +7
F
3 + 6 + 8
G
4 + 5 + 6
H
4 + 6 + 8
Question 6
Which of the following statements is true in relation to the prevalence of hypertension in women after RT?
Option list.
A
> 20% have hypertension
B
> 30% have hypertension
C
> 40% have hypertension
D
> 50 % have hypertension
E
none of the above
Question 7
State whether these drugs are regarded as safe or unsafe in pregnancy.
Drug
Safe / unsafe
A
ACE inhibitor
Safe / unsafe
B
angiotensin receptor antagonist
Safe / unsafe
C
azathioprine
Safe / unsafe
D
ciclosporin
Safe / unsafe
E
clopidogrel
Safe / unsafe
F
erythropoietin
Safe / unsafe
G
hydroxychloroquine
Safe / unsafe
H
mycophenolate
Safe / unsafe
I
prednisolone
Safe / unsafe
J
tacrolimus
Safe / unsafe
K
warfarin
Safe / unsafe
TOG CPD
With regard to renal transplant,
1.     most recipients have a successful pregnancy outcome. T F
2.     pregnancy is associated with a 10% reduction in GFR in recipients with prepregnancy eGFR >90 ml/ min/1.73m2 . T F
3.     hypertension complicates pregnancy in over 50% of recipients who did not require antihypertensive treatment prior to pregnancy. T F
4.     proteinuria is a predictor of poor pregnancy outcome in recipients.  T F
5.     the risk of damage to the allograft at caesarean delivery is about 1%. T F
6.     a positive serological screening test for aneuploidy in recipients is a recognised consequence of impaired renal function. T F
7.     superimposed pre-eclampsia in recipients has defined diagnostic criteria. T F
8.     erythropoietin requirements in recipients fall in pregnancy. T F
9.     breastfeeding is safe in recipients on angiotensin converting enzyme inhibitors. T F
10.   conception is not advised in recipients within the first year following transplantation. T F
11.   continuous electronic fetal monitoring is recommended during labour in recipients. T F
12.   the progesterone implant is a safe form of postpartum contraception in recipients. T F
Women who have donated a kidney,
13.   are at increased risk of gestational hypertension. T F
Combined kidney-pancreas transplant recipients,
14.   have a higher risk of gestational diabetes than kidney transplant recipients. T F
Liver transplant recipients,
15.   have a lower risk of pregnancy complications than renal transplant recipients. T F
With regard to pregnancy in cardiothoracic transplant recipients,
16.   lung transplant recipients have the highest risk of adverse outcome of all solid organ transplants. T F
17.   due to denervation, the transplanted heart responds poorly to the physiological changes of pregnancy. T F
18.   cardiothoracic transplant recipients should be delivered by caesarean section. T F
Regarding medications prescribed in patients with solid organ transplants,
19.   tacrolimus levels require monitoring during pregnancy. T F
20.   warfarin is safe for breastfeeding mothers. T F

16.   EMQ. Abortion Act.
Abortion Act & TOP.
Scenario 1
Lead in.
How many abortions were performed on residents of E&W aged 15-44 in 2016?
Option list
A
about 50,000
B
about 100,000
C
about 150,000
D
about 200,000
E
about 250,000
F
> 250,000
Scenario 2
Lead in.
What was the approximate rate of abortion in E&W residents in 2016?
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
Scenario 3
Lead in.
The rate of abortion has declined by >20% in residents of E&W in the past ten years.
Pick the answer from the option list that best matches the above statement.
Option list
A
False
B
Haven’t a clue
C
Maybe
D
No data exist
E
True
Scenario 4
Lead in.
What proportion of TOPs were performed at gestations <10 weeks in E&W in 2016?
Option list
A
50%
B
60%
C
70%
D
80%
E
90%
Scenario 5
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
Scenario 6
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%
Scenario 7
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%
Scenario 8
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
Scenario 9
Lead in.
What happened to the rate of TOP in 2016 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
Scenario 10
Lead in.
What happened to the rate of TOP in 2015 for girls <16 years compared with 2006?
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
Scenario 11
Lead in.
What happened to the rate of TOP in 2016 for girls <16 years compared with 2015?
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
Scenario 12
Lead in
Approximately what proportion of women having TOP in 2016 had previously had one or more TOPs?
Option list
A
1%
B
5%
C
10%
D
20%
E
30%
F
40%
G
50%
Scenario 13
Lead in
What age group of women 1n 2016 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
Scenario 14
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
Scenario 15
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%
Scenario 16
Lead in
The RCOG recommends that women having TOP should have chlamydia screening. What proportion of women had this done in 2016?
Option list
A
<10%
B
10- 24%
C
25- 49%
D
50- 79%
E
80- 89%
F
≥ 90%
Scenario 17
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
Scenario 18
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
Scenario 19
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
Scenario 20
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
Scenario 21
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
Scenario 22
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
Scenario 23
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.
Scenario 24
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.
Scenario 25
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’s life is at serious risk 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
Scenario 26
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
Scenario 27
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%
Scenario 28
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
Scenario 29
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
Scenario 30
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
Scenario 31
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
Scenario 32
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
Scenario 33
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
Scenario 34
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
Scenario 35
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?
Use the Option list for Question  34.
Scenario 36
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?
Use the Option list for Question  34.

17.   EMQ. Anatomy of fetal skull and maternal pelvis.
Scenario 1.                
How many bones make up the vault of the skull?
Option list.
A.       
3
B.       
5
C.       
6
D.       
7
E.        
8
Scenario 2.                
What is the origin of the word “bregma”?
Option list.
A.       
the Greek word meaning “arrow”
B.       
the Greek word meaning “front of the head”
C.       
the Greek word meaning “top of the head”
D.       
the Greek word meaning “where lines intersect”
E.        
none of the above
Scenario 3.                
What is the origin of the word “lambdoid”?
Option list.
A.       
it is derived from “lambda”, the 11th. letter of the Greek alphabet, with the symbol “λ”
B.       
it is derived from the shape of the rear end of a newborn lamb, with legs apart for balance in the shape of an inverted “V”
C.       
it derives from the Norse noun “lam” meaning to hit
Scenario 4.                
What is the origin of the word “sagittal”?
Option list.
A.       
it derives from the Latin verb “sagire” meaning to be wise
B.       
it derives from the Latin noun “sagitta” meaning “arrow”
C.       
it derives from the Latin adjective “sagitta” meaning “pointing north”
D.       
it derives from the Latin adjective “sagitta” meaning “lacking tension”
Scenario 5.                
What is the meaning of the word “coronal”.
Option list.
A.       
it is the 11th. letter of the Greek alphabet
B.       
it derives from the Latin “corona” meaning “crown”.
C.       
it derives from the sun’s corona, meaning equator
Scenario 6.                
What is the definition of “vertex”?
Option list.
A.       
the most prominent part of the occiput
B.       
the area around the posterior fontanelle
C.       
the area bounded by the anterior fontanelle and the posterior fontanelle
D.       
the area bounded by the anterior & posterior fontanelles and the parietal bones
E.        
the area bounded by the anterior & posterior fontanelles and the parietal eminences
F.        
the area bounded by the anterior & posterior fontanelles and the parietal cardinals
Scenario 7.                
What is the definition of the anterior fontanelle?
Option list.
A.       
the anterior end of the sagittal suture
B.       
the area where the sagittal and coronal sutures meet
C.       
the area between the frontal and parietal bones
D.       
the posterior end of the sagittal suture
E.        
the area between the parietal bones and the occiput
Scenario 8.                
What is the definition of the posterior fontanelle?
Option list.
A.       
the anterior end of the sagittal suture
B.       
the area where the sagittal and lambda sutures meet
C.       
the area between the frontal and parietal bones
D.       
the posterior end of the sagittal suture
E.        
the area between the parietal bones and the occiput
Scenario 9.                
How many other fontanelles are there?
A.       
0
B.       
2
C.       
3
D.       
4
E.        
6
Scenario 10.            
What is the falx cerebri?
Option list.
A.       
an area of dura mater at the back of the skull like a roof over the cerebellum
B.       
is an artefact on ultrasound suggesting the presence of cerebral tissue where there is none
C.       
is the horizontal fibrous platform on which the cerebellum rests
D.       
is a crescent-shaped fold of dura mater separating the cerebral hemispheres
Scenario 11.            
What is the importance of the falx cerebri in relation to delivery, particularly breech delivery?
Option list.
A.       
the falx cerebri is inserted into the tentorium cerebelli and traction on the base of the skull may lead to tentorial tears and intracranial bleeding
B.       
the falx cerebri is inserted into the bone of base of the skull and traction on the base of the skull may lead to tears of the falx and intracranial bleeding
C.       
the falx cerebri is inserted into the tentorium cerebelli and traction on the base of the skull may lead to tentorial tears leaving the cerebellum unsupported and liable to trauma
Scenario 12.            
What diameter presents to the pelvis with vertex presentation?
Option list.
A.       
suboccipito-bregmatic
B.       
suboccipito-frontal
C.       
occipito-frontal
D.       
mento-vertical
E.        
submento-bregmatic
Scenario 13.            
What diameter presents to the pelvis with typical occipito-posterior position?
Option list.
A.       
suboccipito-bregmatic
B.       
suboccipito-frontal
C.       
occipito-frontal
D.       
mento-vertical
E.        
submento-bregmatic
Scenario 14.            
What diameter presents to the pelvis with brow presentation?
Option list.
A.       
suboccipito-bregmatic
B.       
suboccipito-frontal
C.       
occipito-frontal
D.       
mento-vertical
E.        
submento-bregmatic
Scenario 15.            
What diameter presents to the pelvis with mento-anterior face presentation?
Option list.
A.       
suboccipito-bregmatic
B.       
suboccipito-frontal
C.       
occipito-frontal
D.       
mento-vertical
E.        
submento-bregmatic
Scenario 16.            
What diameter presents to the pelvis with mento-posterior face presentation?
Option list.
A.       
suboccipito-bregmatic
B.       
suboccipito-frontal
C.       
occipito-frontal
D.       
mento-vertical
E.        
submento-bregmatic
Scenario 17.            
What is the average length of the suboccipito-bregmatic diameter in a term baby?
Option list.
A.       
  9.0 cm.
B.       
  9.5 cm.
C.       
10.0 cm.
D.       
10.5 cm.
E.        
11.0 cm.
F.        
11.5 cm.
G.       
12.0 cm.
H.       
12.5 cm.
I.         
13.0 cm.
J.         
13.5 cm.
K.        
14.0 cm.
Scenario 18.            
What is the average length of the suboccipito-frontal diameter in a term baby?
Option list.
A.       
  9.0 cm.
B.       
  9.5 cm.
C.       
10.0 cm.
D.       
10.5 cm.
E.        
11.0 cm.
F.        
11.5 cm.
G.       
12.0 cm.
H.       
12.5 cm.
I.         
13.0 cm.
J.         
13.5 cm.
K.        
14.0 cm.
Scenario 19.            
What is the average length of the occipito-frontal diameter in a term baby?
Option list.
A.       
  9.0 cm.
B.       
  9.5 cm.
C.       
10.0 cm.
D.       
10.5 cm.
E.        
11.0 cm.
F.        
11.5 cm.
G.       
12.0 cm.
H.       
12.5 cm.
I.         
13.0 cm.
J.         
13.5 cm.
K.        
14.0 cm.
Scenario 20.            
What is the average length of the mento-vertical diameter in a term baby?
Option list.
A.       
  9.0 cm.
B.       
  9.5 cm.
C.       
10.0 cm.
D.       
10.5 cm.
E.        
11.0 cm.
F.        
11.5 cm.
G.       
12.0 cm.
H.       
12.5 cm.
I.         
13.0 cm.
J.         
13.5 cm.
K.        
14.0 cm.
Scenario 21.            
What is the average length of the submento-bregmatic diameter in a term baby?
Option list.
A.       
  9.0 cm.
B.       
  9.5 cm.
C.       
10.0 cm.
D.       
10.5 cm.
E.        
11.0 cm.
F.        
11.5 cm.
G.       
12.0 cm.
H.       
12.5 cm.
I.         
13.0 cm.
J.         
13.5 cm.
K.        
14.0 cm.

18.   EMQ. Anti-Müllerian hormone
AMH.
Abbreviations.
AFC:         antral follicle count
AFP:         antral follicle pool
AMH:       anti-Müllerian hormone
COC:        combined oral contraceptive
COS:        controlled ovarian stimulation
GnRHA:   gonadotrophin releasing hormone analogue
PCOS:      polycystic ovary syndrome
POF:         premature ovarian failure
SHBG:      sex hormone binding globulin
Question 1.
Lead-in
Which, 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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