Tutorial 23rd. January 2020

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49	SBA. Cancer incidence and mortality.
50	EMQ. Retinoids and pregnancy
51	Viva. Obstructive sleep apnoea
52	EMQ. Drugs in pregnancy 1
53	EMQ. Disorders of sexual development. AIS, MRKH etc.

49.      Cancer incidence and mortality.

Question 1.

Lead-in

Which is the most common female cancer?

Option List

A.	Bowel
B.	Breast
C.	Cervix
D.	Endometrium
E.	Lung

Question 2.

Lead-in

Which is the 2^nd. most common female cancer?

Option List

A.	Bowel
B.	Breast
C.	Cervix
D.	Endometrium
E.	Lung

Question 3.

Lead-in

Which is the 3^rd. most common female cancer?

Option List

A.	Bowel
B.	Breast
C.	Cervix
D.	Endometrium
E.	Lung

Question 4.

Lead-in

Which is the 4^th. most common female cancer?

Option List

A.	Bowel
B.	Cervix
C.	Endometrium
D.	Lung
E.	Pancreas

Question 5.

Lead-in

Which is the 5^th. most common female cancer?

Option List

A.	Cervix
B.	Malignant melanoma
C.	Non-Hodgkin’s lymphoma
D.	Ovary
E.	Vulva

Question 6.

Lead-in

Which is the 6^th. most common female cancer?

Option List

A.	Cervix
B.	Malignant melanoma
C.	Non-Hodgkin’s lymphoma
D.	Ovary
E.	Vulva

Question 7.

Lead-in

Where does cervical cancer feature in the list of the most common female cancers?

Option List

A.	10th.
B.	11th.
C.	13th.
D.	14th.
E.	20th.

Question 8.

Lead-in

Where does vulval cancer feature in the list of the most common female cancers?

Option List

A.	10th.
B.	12th.
C.	16th.
D.	20th.
E.	none of the above

Question 9.

Lead-in

Which is the most common cancer causing female death in the UK?

Option List

A.	Breast
B.	Bowel
C.	Lung
D.	Ovary
E.	Pancreas

Question 10.

Lead-in

Which is the 2^nd. most common cancer causing female death in the UK?

Option List

Use the one for question 9.

Question 11.

Lead-in

Which is the 3^rd. most common cancer causing female death in the UK?

Option List

Use the one for question 9.

Question 12.

Lead-in

Which is the 4^th. most common cancer causing female death in the UK?

Option List

A.	Brain
B.	Oesophagus
C.	Ovary
D.	Pancreas
E.	Uterus

Question 13.

Lead-in

Which is the 5^th. most common cancer causing female death in the UK?

Option List

Use the one for question 12.

Question 14.

Which is the 6^th. most common cancer causing female death in the UK?

Option List

Use the one for question 9.

Question 15.

Lead-in

The incidence of cervical cancer has fallen from the late 1970s until now. What is the approximate figure for the fall?

Option List

A.	10%
B.	25%
C.	50%
D.	60%
E.	75%

Question 16.

Lead-in

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

Option List

A	there were ~ 20,000 new cases of CIN in 2015
B	there were ~ 30,000 new cases of CIN in 2015
C	there were ~ 50,000 new cases of CIN in 2015
D	incidence rates for new cases of CIN are highest in women aged 19 - 24
E	incidence rates for new cases of CIN are highest in women aged 25 - 29
F	incidence rates for new cases of CIN are highest in women aged 30 - 39
G	incidence rates for new cases of CIN ↑ by ~ 10 % since the 1990s
H	incidence rates for new cases of CIN ↑ by ~ 20 % since the 1990s
I	incidence rates for new cases of CIN ↑ by ~ 30 % since the 1990s
J	incidence rates for new cases of CIN ↑ by ~ 5 % in the past decade
K	incidence rates for new cases of CIN ↑ by ~ 10 % in the past decade
L	incidence rates for new cases of CIN ↑ by ~ 15 % in the past decade

Question 17.

Lead-in

Which, if any, of the following statements describes the change in incidence of cervical cancer in the past decade.

Option List

A.	↑ by 5%
B.	↓ by 5%
C.	↑ by 10%
D.	↓ by 10%
E.	↑ by 15%
F.	↓ by 15%
G.	↑ by 20%
H.	↓ by 20%
I.	↑ by 25%
J.	↓ by 25%

Question 18.

Lead-in

What is the peak age at which cervical cancer is diagnosed in the UK?

Option List

A.	20-24
B.	25-29
C.	30-34
D.	35-39
E.	40-44
F.	45-49
G.	50-54
H.	55-59
I.	≥60

Question 19.

Lead-in

What proportion of cervical cancer is diagnosed in women < 45 years?

Option List

A.	20%
B.	30%
C.	40%
D.	50%
E.	60%

Question 20.

Lead-in

The mortality rate from cervical cancer has fallen from the late 1970s until now. What is the approximate figure for the fall?

Option List

A.	10%
B.	25%
C.	50%
D.	60%
E.	75%

Question 21.

Lead-in

The mortality rate from cervical cancer has fallen in the past decade. What is the approximate figure for the fall?

Option List

A.	10%
B.	25%
C.	50%
D.	60%
E.	75%

Question 22.

Lead-in

The mortality rate from cervical cancer has fallen in the past decade. What is the approximate figure for the fall?

Option List

F.	10%
G.	25%
H.	50%
I.	60%
J.	75%

Question 23.

Lead-in

When was routine HPV vaccination of girls introduced in the UK?

Option List

A.	2000
B.	2002
C.	2004
D.	2006
E.	2008

Question 24.

Lead-in

From what year might we expect to see a reduction in cervical cancer incidence as a result of the HPV vaccination programme?

Option List

A.	2020
B.	2025
C.	2030
D.	2040
E.	2050

Question 25.

Lead-in

When was routine HPV vaccination of boys introduced in the UK?

Option List

A.	2010
B.	2011
C.	2012
D.	2014
E.	None of the above

50.      Retinoids and pregnancy.

Retinoids & pregnancy.

I think the questions you are likely to be asked will come from the TOG article by Browne et al and are covered by the associated TOG CPD questions.

Hannah Browne, Gerald Mason and Thomas Tang: “Retinoids and pregnancy”.

TOG. 2014. Volume16, Issue1, Pages 7-11.

The article and CPD questions are open access and reproduced here.

With regard to isotretinoin,

1.     its mode of action is to reduce sebum secretion.                                                       True False

2.     it is used as a first-line treatment for acne.                                                                 True False

3.     it has an elimination half-life of less than 10 hours.                                                  True False

4.     the dose prescribed is adjusted according to the patient’s weight.                        True False

5.     the estimated pregnancy rate while on treatment is around 1%.                           True False

Regarding side effects of retinoids (such as isotretinoin) including their teratogenicity,

6.     mood disturbance is well documented.                                                                       True False

7.     derivatives of the mesonephric duct are recognised malformations.                     True False

8.     limb deformities are common.                                                                                       True False

9.     their use in pregnancy is associated with ear abnormalities.                                   True False

With regard to the incidence of teratogenic effects of isotretinoin,

10.   30% of affected fetuses have been reported to perform poorly in neuropsychological tests.

11.   approximately half of fetuses exposed to them suffer from mental retardation.             True False

12.   about a third of fetuses exposed to them have retinoid specific fetal malformations.       True False

Concerning the pregnancy prevention programme in those being placed on isotretinoin;

13.   the programme was launched in 2005 in the UK.                                                       True False

14.   contraception should be used for 1 month prior to and 2 months following treatment.

                                                                                                                                                      True False

15.   pregnancy tests should be taken monthly throughout treatment.                         True False

16.   exerts its teratogenic effect through a mechanism that does not significantly affect vitamin A levels.                                                                                                                                        True False

17.   affects the development of the branchial arches by effecting haemopexin signalling.        True False

18.   is associated with a miscarriage of over 20% when used in the first trimester. True False

Concerning retinoid embryopathy,

19.   topical application is not associated with an increased risk.                                    True False

20.   the most common malformations are those of the musculoskeletal system.                     True False

Breastfeeding does not feature in the TOG questions.

Retinoid use is safe during breastfeeding.                                                                           True False

Retinoid use is safe during breastfeeding.                                                                            True False

51.      Obstructive sleep apnoea.

Candidate's Instructions.

This is a structured discussion station. The examiner will ask you 11 questions. When you have answered a question and moved to the next, you are not allowed to return as later questions may give answers to earlier ones.

52.      Drugs in O&G 1.

Abbreviations.

ACE:              angiotensin-converting enzyme

ACEI:            angiotensin-converting enzyme inhibitor

ARA:             angiotensin II receptor antagonist

HG:               hyperemesis gravidarum

IUGR:            intra-uterine growth retardation

LDA:              low-dose aspirin

MAOI:          monoamine oxidase inhibitor

Option list.

a)         False.

b)         True.

c)         5

d)         10

e)         15

f)          18

g)         20

h)         24

i)           contraindicated in the months before pregnancy

j)           contraindicated in the 1^st. trimester

k)         contraindicated in the 2^nd. trimester

l)           contraindicated in the 3^rd. trimester

m)       contraindicated in all trimesters

n)         not contraindicated in pregnancy

o)         contraindicated in breastfeeding

p)         not contraindicated in breastfeeding

q)         an acute, severe illness like rheumatoid arthritis

r)          an acute, severe illness with encephalopathy and acute fatty liver

s)          an acute, severe illness with gastro-intestinal tract bleeding

t)      there is insufficient information to be able to provide advice

Scenario 1.

When are ACE inhibitors contraindicated in pregnancy?

Scenario 2.

When are ARAs contraindicated in pregnancy?

Scenario 3.

Can St. John’s Wort (SJW) be used in pregnancy?

Scenario 4.

Methyldopa is an acceptable option for the treatment of gestational hypertension. True / False.

Scenario 5.

Spironolactone is contraindicated in pregnancy. True/False

Scenario 6.

Furosemide is an acceptable option in the management of gestational hypertension. True / False.

Scenario 7.

When and why are thiazide diuretics contraindicated in pregnancy?

Scenario 8.

Salbutamol is contraindicated for the management of premature labour. True / False.

Scenario 9.

Ergometrine is an integral part of active management of the 3^rd. stage.  True / False.

Scenario 10.

When is aspirin contraindicated in pregnancy & the puerperium?

Scenario 11.

When are NSAID’s contraindicated in pregnancy and why?

Scenario 12.

Pethidine: adverse neonatal effects are most likely if the drug is administered in the six hours before birth.  True / False.

Scenario 13.

Pethidine: what is the half-life in the mature neonate?

Scenario 14.

Pethidine is contraindicated in those taking MOAIs or who have taken them in the previous 2 months. 

Scenario 15.

Pethidine is relatively contra-indicated when there is significant blood loss.  True / False.

Scenario 16.

Pethidine has greater analgesic effect in labour than Diamorphine.                  True / False.

Scenario 17.

What is Reye’s syndrome and which family of drugs is particularly linked?

Scenario 18.

What is “torsades de pointes” and when is it of importance in the management of HG?

53.         AIS, MRKH and Swyer’s syndrome

Abbreviations.

AIS:       androgen insensitivity syndrome.

AMH:    anti-Mullerian hormone.

CAH:     congenital adrenal hyperplasia.

CAI:       complete androgen insensitivity syndrome.

DSD:     disorder of sexual differentiation.

KS:         Kallmann’s syndrome.

LMB:     Laurence-Moon-Biedl syndrome.

MRKH:  Mayer-Rokitansky- Küster-Hauser syndrome.

PAI:       partial androgen insensitivity syndrome.

PW:       Prader-Willi syndrome.

SW:       Swyer’s syndrome.

TU:        Turner’s syndrome.

UPD:     uni-parental disomy.

Option list 1.

A.         has a uterus of normal size for her age.

B.         has a uterus that is hypoplastic for her age.

C.         has a vestigial uterus (anlagen).

D.        has no uterus.

E.         commonly has esthiomene

F.         I don’t know and I don’t care.

G.        the question makes no sense.

H.        none of the above.

Scenarios.

1.     a girl with congenital adrenal hyperplasia at the start of puberty.

2.     a girl with complete androgen insensitivity syndrome at the start of puberty.

3.     a girl with a disorder of sexual differentiation at the start of puberty.

4.     a girl with Kallmann’s syndrome at the start of puberty.

5.     a girl with Laurence-Moon-Biedl syndrome at the start of puberty.

6.     a girl with Mayer-Rokitansky-Kuster-Hauser syndrome at the start of puberty.

7.     a girl with partial androgen insensitivity syndrome at the start of puberty.

8.     a girl with Prader-Willi syndrome at the start of puberty.

9.     a girl with Swyer’s syndrome at the start of puberty.

10.   a girl with Turner’s syndrome at the start of puberty.