Tutorial 17th June 2019

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22	Viva. Obstructive sleep apnoea
23	EMQ. Renal transplant
24	SBA. Endometrial hyperplasia
25	EMQ. Headache
26	EMQ. Abortion Act
27	SBA. Kisspeptin

22. Viva. Obstructive sleep apnoea

The examiner will ask you 11 questions.

23. EMQ. Renal transplant & pregnancy.

Abbreviations.

AST:      American Society for Transplantation

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 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

24. EMQ. Endometrial hyperplasia.

Abbreviations.

BSO:     bilateral salpingo-oophorectomy

c.f.         compared with

EC:        endometrial cancer

EH:        endometrial hyperplasia

ES:         endometrial surveillance

Question 1.

What is the definition of endometrial hyperplasia?

Option List

A.	endometrial thickness ≥ twice that of proliferative endometrium
B.	endometrial thickness ≥ twice that of proliferative endometrium in the absence of oestrogenic stimulation
C.	premenopausal endometrial thickness ≥ 6 mm; postmenopausal thickness ≥ 4 mm.
D.	proliferation of endometrial glands with ↑ gland to stroma ratio c.f. proliferative endometrium
E.	proliferation of endometrial stroma with ↑ stroma to gland ratio c.f. proliferative endometrium

Question 2.

Approximately how many cases of endometrial cancer are diagnosed annually in the UK?

Option List

	≤ 1,000
	1,000 - ≤ 1,500
	1,500 - ≤ 3,000
	3,000 - ≤ 5,000
	5,000 - ≤ 10,000

Question 3.

Where does endometrial cancer rank in the list of gynaecological cancers by incidence?

Option List

A.	1st.
B.	2nd.
C.	3rd.
D.	4th.
E.	5th.

Question 4.

Where does endometrial cancer rank in the list of gynaecological cancers causing death?

Option List

A.	1st.
B.	2nd.
C.	3rd.
D.	4th.
E.	5th.

Question 5.

What is the prevalence of EH compared with that of EC.?

Option List

A.	~ ¼
B.	~ ½
C.	similar
D.	> double
E.	> treble

Question 6.

What classification system does the RCOG recommend for EH?

Option List

A.	BSGE 2015 classification based on endometrial thickness
B.	FIGO 2000 classification based on risk of malignancy assessment
C.	FIGO 2005 classification based on histological grading
D.	WHO 2014 classification based on endometrial thickness
E.	WHO 2014 classification based on cytological atypia

Question 7.

A 48-year-old woman presents with erratic bleeding and menopausal symptoms. Endometrial histology shows hyperplasia with no cytological anomaly. What is the risk of progression to endometrial cancer in the next 10 years?

Option List

A.	< 1%
B.	≤ 5%
C.	5% - ≤ 10%
D.	10% - ≤ 15%
E.	> 15%

Question 8.

A 48-year-old woman presents with menopausal symptoms. Endometrial histology shows hyperplasia with no cytological anomaly. What is the chance of spontaneous regression of the endometrial hyperplasia?

Option List

A.	< 1%
B.	1% - ≤ 10%
C.	10% - ≤ 15%
D.	15% - ≤ 25%
E.	> 25%

Question 9.

A 48-year-old woman presents with erratic bleeding and menopausal symptoms. An outpatient endometrial sample shows atypical hyperplasia. What is her lifetime risk of EC?

Option List

A.	≤ 5%
B.	5% - ≤ 10%
C.	10% - ≤ 25%
D.	25% - ≤ 50%
E.	> 50%

Question 10.

Which of the following are risk factors for the development of endometrial hyperplasia?

Option List

A.	aromatase inhibitors
B.	clomiphene used for induction of ovulation
C.	continuous combined HRT
D.	obesity
E.	tamoxifen

Question 11.

Which of the following should be used for the diagnosis of endometrial hyperplasia?

Option List

A.	endometrial histology
B.	CT scan
C.	hystero-salpingography
D.	MRI scan
E.	trans-vaginal ultrasound scan

Question 12.

Which of the following are true of the management of endometrial hyperplasia without cytological abnormality?

Option List

A.	identified risk factors should be discussed with the woman
B.	observation with follow-up endometrial biopsies is acceptable
C.	progestogens improve the chance of regression
D.	progestogen should not be used when women show no regression after B
E.	progestogen should not be used when women have abnormal bleeding

Question 13.

Which of the following are true of the management of endometrial hyperplasia without cytological abnormality?

Option List

A.	brachytherapy is the recommended 1st. line treatment in the GTG
B.	cyclical oral progestogen therapy is the recommended 1st. line treatment in the GTG
C.	intra-cavity methotrexate is the recommended 1st. line treatment in the GTG
D.	the COC is the recommended 1st. line treatment in the GTG
E.	the LNG-IUS is the recommended 1st. line treatment in the GTG

Question 14.

Which of the following statements are true in relation to the management of endometrial hyperplasia without cytological abnormality?

Option List

A.	treatment should be for a minimum of 6 months
B.	women should be encouraged to continue with the LNG-IUS for at least 3 years
C.	endometrial surveillance with biopsy should be provided at a minimum of 12 monthly
D.	review schedules should be individualised
E.	two consecutive 6-monthly biopsies should be negative before discharge is considered

Question 15.

Which of the following are true in relation to hysterectomy as management of endometrial hyperplasia without cytological abnormality?

Option List

A.	treatment to achieve regression should be for at least 6 months before surgery is considered
B.	treatment to achieve regression should be for at least 12 months before surgery is considered
C.	treatment to achieve regression should be for at least 24 months before surgery is considered
D.	recurrence of endometrial hyperplasia without cytological abnormality after progestogen therapy is grounds for considering hysterectomy
E.	hysterectomy should be recommended to the woman who declines surveillance

Question 16.

 Which of the following statements are true in relation to women with endometrial hyperplasia without cytological atypia for whom hysterectomy is being considered?

Option List

A.	post-menopausal women should have bilateral salpingo-oophorectomy
B.	pre-menopausal women should have bilateral salpingo-oophorectomy
C.	bilateral salpingectomy should be offered to all women not having BSO
D.	laparoscopic hysterectomy should be offered in preference to abdominal
E.	the GTG uses the term “total hysterectomy” which is really stupid

Question 17.

Which of the following are true in relation to the management of atypical hyperplasia of the endometrium?

Option List

A.	endometrial ablation is satisfactory if ES can be done for at least 5 years
B.	brachytherapy is satisfactory if ES can be done for at least 5 years
C.	hysterectomy ± BSO or bilateral salpingectomy should be offered
D.	frozen section should be done at the time of hysterectomy to determine the need for lymphadenectomy
E.	continuous oral progestogen therapy should be given for at least 12 months post-op

Question 18.

A woman with atypical hyperplasia of the endometrium wishes to retain her fertility. Which of the following are true?

Option List

A.	endometrial and ovarian cancer must be ruled out to start with
B.	the MDT should decide management after reviewing the results of the histology, imaging and tumour markers
C.	the woman should be advised is that medical advice is to have hysterectomy because of the risk of cancer
D.	the LNG-IUS is the first-line preference for conservative management
E.	oral progestogens should not be used
F.	she should have at least one clear endometrial biopsy before conceiving
G.	referral to a fertility specialist should be arranged to discuss ART

Question 19.

What follow-up should be offered to the woman with atypical hyperplasia of the endometrium who wishes conservative management?

Option List

A.	surveillance includes endometrial biopsy
B.	surveillance should be at intervals of not more than 6 months until 2 consecutive, clear biopsies have been obtained
C.	surveillance should be at intervals of not more than 3 months until 2 consecutive, clear biopsies have been obtained
D.	long-term follow-up after 2 consecutive, clear biopsies have been obtained can be at 6 – 12 month intervals
E.	long-term follow-up after 2 consecutive, clear biopsies have been obtained can be at 12 – 24 month intervals

Question 20.

A woman who has had successful conservative treatment for atypical hyperplasia of the endometrium wishes to go onto HRT. Which of the following are true?

Option List

A.	continuous progestogen therapy is necessary regardless of the type or mode of administration of oestrogen replacement
B.	LNG-IUS or depot progestogens are preferred to oral therapy
C.	hysterectomy should be recommended if not already done
D.	six-months TV scans should be done for endometrial thickness
E.	none of the above

Question 21.

Which of the following are true in relation to the woman with endometrial hyperplasia who has been treated for breast cancer and are taking tamoxifen or aromatase inhibitors.

Option List

A.	she should be informed that tamoxifen ↑the risk of endometrial cancer
B.	she should be informed that aromatase inhibitors ↑the risk of endometrial cancer
C.	she should be informed that the LNG-IUS ↓ the risk of endometrial cancer for women on tamoxifen
D.	she should be informed that the LNG-IUS ↓ the risk of endometrial cancer for women on aromatase inhibitors
E.	she should be informed that the effect of the LNG-IUS on the risk of breast cancer recurrence is unknown and that it is not recommended as a result

Question 22.

A woman is found to have endometrial hyperplasia on an endometrial polyp. Which of the following are true of the best management?

Option List

A.	complete removal of the polyp must be checked
B.	hysteroscopy and curettage must be done to check the endometrium
C.	an LNG-IUS should be recommended
D.	hysterectomy should be recommended
E.	none of the above.

25. EMQ. Headache.

Lead-in.

The following scenarios relate to headache in pregnancy.

Pick one option from the option list.

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

Option list.

1.      abdominal migraine

2.      analgesia overuse aka medication overuse

3.      bacterial meningitis

4.      benign intracranial hypertension

5.      BP check

6.      cerebral venous sinus thrombosis

7.      chest X-ray

8.      cluster

9.      severe PET / impending eclampsia

10.  malaria

11.  meningococcal meningitis

12.  methyldopa

13.  methysergide

14.  migraine

15.  MRI brain scan

16.  nifedipine

17.  nitrofurantoin

18.  pancreatitis

19.  sinusitis

20.  subdural haematoma

21.  subarachnoid haemorrhage

22.  tension

23.  ultrasound scan of the abdomen

Scenario 1.

A 40-year-old para 3 is admitted at 38 weeks by ambulance with severe headache of sudden onset. She describes it as “the worst I’ve ever had”. Which diagnosis needs to be excluded urgently?

Scenario 2.

A 32-year-old para 1 has recently experienced headaches. They are worse on exercise, even mild exercise such as walking up stairs. She experiences photophobia with the headaches. Which is the most likely diagnosis?

Scenario 3.

A woman returns from a sub-Saharan area of Africa. She develops severe headache, fever and rigors. What diagnosis should particularly be in the minds of the attending doctors?

Scenario 4.

A woman at 37 weeks has s. They particularly occur at night without obvious triggers. They occur every few days.

Scenario 5.

A primigravida has had s on a regular basis for many years. They occur most days, are bilateral and are worse when she is stressed. What is the most likely diagnosis?

Scenario 6.

A woman complains of recent headaches at 36 weeks. The history reveals that they started soon after she began treatment with a drug prescribed by her GP. Which is the most likely of the following drugs to be the culprit: methyldopa, methysergide, nifedipine or nitrofurantoin?

Scenario 7

A woman is booked for Caesarean section and wishes regional anaesthesia. She had severe headache due to dural tap after a previous Caesarean section. She wants to take all possible steps to reduce the risk of having this again. Which of epidural / spinal anaesthesia has the lower risk of causing dural tap?

Scenario 8

A 25-year-old primigravida attends for her 20-week scan and complains of headache which started two weeks before. There is no significant history. The pain occurs behind her right eye and she describes it as severe and “stabbing” in nature. The pain is so severe that she cannot sit still and has to walk about. She has noticed that her right eye becomes reddened and “watery” during the attack and her nose is “runny”. The attacks have no obvious trigger and mostly occur a few hours after she has gone to sleep. The usually last about 20 minutes. She has no other symptoms. She smokes 20 cigarettes a day but does not take any other drugs, legal or otherwise. What is the most likely diagnosis?

Scenario 9

A woman has a 5-year history of unilateral, throbbing headache often preceded by nausea, visual disturbances, photophobia and sensitivity to loud noise. What is the most likely diagnosis?

Scenario 10

A primigravida is admitted at 38 weeks complaining of headache, abdominal pain and a sensation of flashing lights. What would be the appropriate initial investigation?

Scenario 11

A woman with BMI of 35 attends for her combined Downs syndrome screening test. She complains of pain behind her eyes. The pain is worst last thing at night before she goes to sleep or if she has to get up in the night. She has noticed she has noticed horizontal diplopia on several occasions. She has no other symptoms. Examination shows papilloedema.

Scenario 12

A grande multip of 40 years experienced sudden-onset, severe headache, vomited several times and then collapsed, all within the space of 30 minutes. She is admitted urgently in a semi-comatose state. Examination shows neck-stiffness and left hemi-paresis.

Scenario 13.

What did the MMR include as “red flags” for headache in pregnancy? These are not on the option list – you need to dig them out of your head.

Questions from TOG article by Revell & Moorish. 2014. This is open access, so read it.

https://obgyn.onlinelibrary.wiley.com/doi/10.1111/tog.12101. 

Headaches in pregnancy

Red flag features for headaches include:

1.     headache that changes with posture True / False

2.     associated vomiting True / False

3.     occipital location True / False

4.     associated visual disturbance. True / False

Migraine is classically,

5.     bilateral. True / False

6.     pulsating. True / False

7.     aggravated by physical exercise. True / False

With regard to migraine headaches in pregnancy,

8.     there is an increase in the frequency of attacks without aura. True / False

9.     women who suffer from this have not been shown to have an increase in the risk of pre-eclampsia. True / False

10.   the 5HT1-receptor sumatriptan has been shown to be teratogenic. True / False

11.   women presenting with an aura for the first time are not at an increased risk of intracranial disease. True / False Posterior reversible encephalopathy syndrome,

12.   is associated with an impairment of the autoregulatory mechanism which maintains constant cerebral blood flow where there are blood pressure fluctuations. True / False

13.   when it is associated with pre-eclampsia, management should follow the pathway for managing severe pre-eclampsia. True / False

With regard to cerebral venous thrombosis,

14.   the incidence in western countries in pregnancy ranges from 1 in 2500 deliveries to 1 in 10 000 deliveries. True / False

15.   the greatest risk in pregnancy is mainly in the last four weeks. True / False

16.   the most common site is the sagittal sinus. True / False

17.   a plain computed tomography is a highly sensitive investigation. True / False

18.   T2-weighted magnetic resonance imaging has been shown to have limited value in diagnosis. True / False

19.   the outcome is better when it is associated with pregnancy and the puerperium compared to that occurring outside pregnancy. True / False

20.   when it occurs in pregnancy, it is a contraindication for future pregnancies. True / False

26. EMQ. 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 1^st. 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.

27. EMQ. Kisspeptin.

Lead in.

Pick the best answer from the list below about kisspeptin.

Option list.

A	is a pheromone released by the salivary glands during passionate embraces
B	is a digestive enzyme released by the salivary glands during passionate embraces
C	is a digestive enzyme found in human carnivores but not vegetarians
D	is thought necessary for trophoblastic invasion and low levels have been linked to miscarriage, recurrent miscarriage and ↑ risk of PET
E	is named after “Kiss me quick” chocolate
F	does not exist and this question is a very poor joke by someone who should know better