Tutorial 6th. January 2019

Contact us

Website

41	EMQ. Maternal mortality definitions
42	EMQ. Zika virus and pregnancy
43	EMQ. BRCA1 & 2
44	EMQ. Cervical cancer staging

41.         Maternal Mortality Definitions.

Option List.

1.         Death of a woman during pregnancy and up to 6 weeks later, including accidental and incidental causes.

2.         Death of a woman during pregnancy and up to 6 weeks later, excluding accidental and incidental causes.

3.         Death of a woman during pregnancy and up to 52 weeks later, including accidental and incidental causes.

4.         Death of a woman during pregnancy and up to 52 weeks later, excluding accidental and incidental causes.

5.         A pregnancy going to 24 weeks or beyond.

6.         A pregnancy going to 24 weeks or beyond + any pregnancy resulting in a live-birth.

7.         Maternal deaths per 100,000 maternities.

8.         Maternal deaths per 100,000 live births.

9.         Direct + indirect deaths per 100,000 maternities.

10.     Direct + indirect deaths per 100,000 live births.

11.     Direct death.

12.     Indirect death.

13.     Early death.

14.     Late death.

15.     Extra-late death.

16.     Fortuitous death.

17.     Coincidental death.

18.     Accidental death.

19.     Maternal murder.

20.     Not a maternal death.

21.     Yes

22.     No.

23.     I have no idea.

24.     None of the above.

Abbreviations.

MMR:      Maternal Mortality Rate.

MMRat:  Maternal Mortality Ratio.

SUDEP:    Sudden Unexplained Death in Epilepsy.            

Scenario 1. What is a Maternal Death?

Scenario 2. A woman dies from a ruptured ectopic pregnancy at 10 weeks’ gestation. What kind of death is it?

Scenario 3. A woman dies from a ruptured appendix at 10 weeks’ gestation. What kind of death is it?

Scenario 4. A woman dies from suicide at 10 weeks’ gestation. What kind of death is it?

Scenario 5. A woman with a 10-year-history of coronary artery disease dies of a coronary thrombosis at 36 weeks’ gestation. What kind of death is it?

Scenario 6. A woman has gestational trophoblastic disease, develops choriocarcinomas and dies from it 24 months after the GTD was diagnosed and the uterus evacuated. What kind of death is it?

Scenario 7. A woman develops puerperal psychosis from which she makes a poor recovery. She kills herself when the baby is 18 months old. What kind of death is it?

Scenario 8. A woman develops puerperal psychosis from which she makes a poor recovery. She kills herself when the baby is 6 months old. What kind of death is it?

Scenario 9. What is a “maternity”.

Scenario 10. What is the definition of the Maternal Mortality Rate?

Scenario 11. What is the Maternal Mortality Ratio?

Scenario 12. A woman is diagnosed with breast cancer. She has missed a period and a pregnancy test is +ve. She decides to continue with the pregnancy. The breast cancer does not respond to treatment and she dies from secondary disease at 38 weeks. What kind of death is it?

Scenario 13. A woman who has been the subject of domestic violence is killed at 12 weeks’ gestation by her partner. What kind of death is it?

Scenario 14. A woman is struck by lightning as she runs across a road. As a result she falls under the wheels of a large lorry which runs over abdomen, rupturing her spleen and provoking placental abruption. She dies of haemorrhage, mostly from the abruption. What kind of death is it?

Scenario 15. A woman is abducted by Martians who are keen to study human pregnancy. She dies as a result of the treatment she receives. As this death could only have occurred because she was pregnant, is it a direct death?

Scenario 16. Could a maternal death from malignancy be classified as “Direct”.

Scenario 17. Could a maternal death from malignancy be classified as “Indirect”.

Scenario 18. Could a maternal death from malignancy be classified as “Coincidental”?

Scenario 19. A pregnant woman is walking on the beach at 10 weeks when she is struck by lightning and dies. What kind of death is this?

Scenario 20. A woman is sitting on the beach breastfeeding her 2-month old baby when she is struck by lightning and dies. What kind of death is this.

42          Zika virus & pregnancy.

Abbreviations.

CZVS:          Congenital Zika Virus Syndrome.

FMS:           fetal medicine specialist.

HC               head circumference.

PHE:           Public Health England.

PCR:            polymerase chain reaction.

RTPCR:       Reverse transcription polymerase chain reaction

Question 1.              

What kind of virus is Zika?

A	DNA
B	DNA + RNA during intermediate stage
C	RNA
D	RNA + DNA during intermediate stage

Question 2.              

To which family of viruses does the Zika virus belong?

A	adenoviruses
B	flaviviruses
C	herpesviruses
D	orthomyxoviruses
E	parvoviruses
F	picornaviruses
G	retroviruses
H	togaviruses

Question 3.              

What other human infections are caused by viruses from this family? This is not a proper EMQ: there may be more than one correct answer.

A	bubonic plague
B	chikungunya
C	chicken pox
D	common cold
E	dengue fever
F	hepatitis C
G	Japanese encephalitis
H	malaria
I	San Francisco encephalitis
J	St. Louis encephalitis
K	West Nile virus
L	Yellow fever

Question 4.              

When was the first reported identification of Zika virus infection in an animal and what was the animal?

A	1922 in a hippopotamus
B	1928 is a giraffe
C	1935 in a macaque monkey
D	1947 in a Rhesus negative monkey
E	1950 in a chimpanzee
H	none of the above.

Question 5.              

Why is the virus called “Zika”?

A	it was first described as “zoonosis affecting Intestines, Kidneys and Adrenals”
B	the animal from which it was first isolated was the Zika monkey
C	it was first isolated from a monkey from the Zika area of Zambia
D	it was first isolated from a monkey from the Zika forest in Uganda
E	it was first identified in the Zika laboratory of the CDC
F	it was first identified by Dr Emily Zika, Professor of Virology, Pretoria, S Africa
G	Zika is the Zulu word for ‘small head’ and the association was 1st. noted in a Zulu baby

Question 6.              

What is the main reservoir of the Zika virus?

A	anteaters
B	horses
C	humans
D	marmosets
E	monkeys
F	parrots
G	rats

Question 7.              

How is the Zika virus transmitted? This is not a true EMQ as there may be > 1 correct answer.

A	Aedes aegypti mosquitos
B	Aedes albopictus: Asian tiger mosquito
C	Anopheles gambiae mosquitos
D	Culex pipiens  mosquitos
E	fleas
F	ticks
G	worms
H	none of the above.

Question 8.              

At what time of day is transmission of infection most likely?

A	afternoon
B	evening
C	morning
D	night
E	mid-morning and mid-afternoon to dusk
F	two hours after sunrise
G	two hours before sunset
H	two hours after sunset
I	two hours after sunrise and two hours before sunset
J	none of the above

Question 9.              

Where do aegypti mosquitoes breed?

Which, if any of the following

A	in large stretches of water with reed beds
B	in water near human habitation
C	in water remote from human habitation
D	in water in human habitations
E	in water with volume > 5 litres
F	in water with volume > 50 litres
G	in water with volume > 500 litres
H	none of the above.

Question 10.          

When did the current interest in the Zika virus and pregnancy begin and why?

A	Brazil reported an ↑ in microcephaly with a possible link to maternal Zika infection in 2014
B	Brazil reported an ↑ in microcephaly with a possible link to maternal Zika infection in 2015
C	Brazil reported an ↑ in microcephaly with a possible link to maternal Zika infection in 2016
D	the CDC reported 3 cases of microcephaly after proven Zika infection in pregnancy in 2014
E	the CDC reported 3 cases of microcephaly after proven Zika infection in pregnancy in 2015
F	the CDC reported 3 cases of microcephaly after proven Zika infection in pregnancy in 2016
H	none of the above

Question 11.          

How did the WHO categorise the problem and when?

A	Public Health Emergency of International Concern 2015
B	Public Health Emergency of International Concern 2016
C	Public Health Emergency of International Concern 2017
D	Public Health Emergency of International Concern 2018
E	none of the above

Question 12.          

Is Zika virus infection a notifiable condition in the UK?

A	No
B	Yes, but only if people have returned from an area with a high prevalence of Zika
C	Yes, but only if the woman and her partner have returned from an area with high prevalence of Zika
D	Yes, but only if fetal damage has occurred.
E	none of the above

Question 13.          

How is the risk of getting a Zika virus infection from travelling to a particular country categorised? Which, if any, of the following feature?

A	frightful
B	high
C	low
D	moderate
E	scary
F	none of the above

Question 14.          

How long does it take for symptoms of Zika infection to develop?

A	1 – 5 days
B	1 – 7 days
C	2 – 5 days
D	2 – 7 days
E	2 – 10 days
F	3 – 7 days
G	3 – 12 days
H	5 – 10 days

Question 15.          

How long do symptoms of Zika infection last?

A	1 – 5 days
B	1 – 7 days
C	2 – 5 days
D	2 – 7 days
E	2 – 10 days
F	3 – 7 days
G	3 – 12 days
H	5 – 10 days

Question 16.          

What are the most common symptoms of Zika infection? There is no option list – write what you think.

Question 17.          

Is Zika infection more severe in pregnancy?

A	No
B	Yes

Question 18.          

What abnormalities have been associated with Congenital Zika Virus Syndrome? There is no option list, just write as many as you can think of.

Question 19.          

What is the approximate risk of vertical transmission of the Zika virus in pregnancy?

A	10%
B	20%
C	30%
D	40%
E	≥ 50%
E	the figure is unknown

Question 20.          

Is gestation related to the risk of vertical transmission of the Zika virus? Which, if any, of the following statements are true?

A	evidence is unclear
B	evidence suggests it probably is
C	evidence suggests it probably is not
D	no
E	yes

Question 21.             

What is the risk of adverse fetal outcomes for women proven to have had Zika virus infection?

A	~   5%
B	~ 10%
C	~ 15%
D	~ 20%
E	~ 25%
F	~30%
G	> 30%
H	none of the above

Question 22.          

What advice should be given to a pregnant woman planning to travel to an area with high risk of transmission of Zika infection?

A	consider postponing travel until after the pregnancy
B	don’t go to the area
C	get vaccinated
D	stay indoors from dawn to dusk
E	take chloroquine as prophylaxis
F	take chloroquine + proguanil as prophylaxis
G	take proguanil as prophylaxis

Question 23.          

What advice should be given to a pregnant woman planning to travel to an area with moderate risk of transmission of Zika infection?

A	consider postponing travel until after the pregnancy
B	don’t go to the area
C	get vaccinated
D	stay indoors from dawn to dusk
E	take chloroquine as prophylaxis
F	take chloroquine + proguanil as prophylaxis
G	take proguanil as prophylaxis

Question 24.          

What advice should be given to a woman who decides to travel to an area of high or moderate risk?

There is no option list: jot down everything you think would be relevant.

Question 25.          

A woman returns to the UK from a high-risk Zika area? She develops symptoms suggestive of Zika infection 4 weeks later. What testing should be offered?

A	abdominal ultrasound
B	amniocentesis
C	MR scan
D	no test indicated
E	TVS
F	Zika IgA
G	Zika IgG
H	Zika IgG + IgM
I	Zika IgA + IgG + IgM
J	Zika PCR

Question 26.          

A woman who wishes to be pregnant has returned to the UK from an area of high-risk for Zika infection. Her partner had remained in the UK? What advice should she be given?

A	use barrier contraception for 8 weeks
B	use effective contraception for 8 weeks
C	use barrier contraception + effective contraception for 8 weeks
D	use barrier contraception for 12 weeks
E	use effective contraception for 12 weeks
F	use barrier contraception + effective contraception for 12 weeks

Question 27.          

A man travels to an area with high-risk of Zika infection? On his return to the UK his wife is keen to start a pregnancy. What advice should be given?

A	use barrier contraception for 8 weeks
B	use effective contraception for 8 weeks
C	use effective contraception + barrier contraception for 8 weeks
D	use barrier contraception for 12 weeks
E	use effective contraception for 12 weeks
F	use effective contraception + barrier contraception for 12 weeks
G	use barrier contraception for 6 months
H	use effective contraception for 6 months
I	use effective contraception + barrier contraception for 6 months
J	none of the above.

Question 28.          

A man travels to an area with high-risk of Zika infection for two weeks? During his stay he has symptoms suggestive of Zika infection. His wife is pregnant. What testing should be offered on his return?

A	discuss with local infection specialist
B	discuss with RIPL
C	no test indicated
D	Zika IgG
E	Zika IgG + IgM
F	Zika IgA + IgG + IgM
G	Zika PCR
H	none of the above

Question 29.          

A woman is shown to have had a Zika infection? How useful is amniocentesis for assessing the risk to the fetus and determining if an infected fetus in affected?

A	PCR on amniocentesis is the gold standard for diagnosing fetal infection
B	PCR on amniocentesis is of unknown value for diagnosing fetal infection
C	PCR on amniocentesis is of little value for diagnosing fetal infection
D	PCR on amniocentesis is the gold standard for determining the risk of an infected fetus being affected
E	PCR on amniocentesis is of unknown value for determining the risk of an infected fetus being affected
F	PCR on amniocentesis is of little value for diagnosing fetal infection

Question 30.          

What advice and treatment should be offered to the non-pregnant individual with symptoms of Zika infection? This is not a true EMQ as more than one option could be true.

A	adequate fluids
B	acyclovir from GP
C	bed rest for 48 hours
D	emergency contraception
E	get advice from A&E centre
F	offer TOP
G	paracetamol if needed for pain

Question 31.          

A pregnant woman returns from a high-risk Zika area and develops symptoms suggestive of infection? She develops a high fever and is admitted to hospital. What particular things should be done?

A	anticoagulant prophylaxis
B	paracetamol + tepid sponging
C	exclude chikungunya
D	exclude dengue
E	exclude malaria
F	exclude UTI
G	exclude Zika
H	exclude other causes of pyrexial illness
I	offer TOP
J	none of the above

Question 32.             

A woman with possible Zika exposure has a –ve test for virus antibodies 4 weeks after the last possible exposure. Is this sufficiently long to reassure her that she has not been infected?

A	no
B	yes
C	we don’t know

Question 33.          

A pregnant woman has visited a country with high-risk for Zika exposure but been asymptomatic during her stay and for two weeks on her return? What testing should be offered?

A	baseline ultrasound + repeat at 18-20 weeks
B	baseline ultrasound + repeat at 28-30 weeks
C	baseline ultrasound + repeat at 18-20 weeks + consider repeat at 28-30 weeks
D	amniocentesis
E	MR scan
F	no test indicated
G	Zika IgG
H	Zika IgG + IgM
I	Zika IgA + IgG + IgM
J	Zika PCR

Question 34.          

A pregnant woman returns to the UK from an area of high risk for Zika exposure has normal ultrasound scans on her return and at 22 weeks. What further scans, if any, should be arranged? This question is in the exam database.

A	monthly scans
B	scan at 28-30 weeks
C	scan at 32 and 36 weeks
D	scan at 36 weeks
E	no further scans
F	none of the above

Question 35.          

A pregnant woman with possible Zika exposure has an ultrasound scan showing the fetal BPD to be > 2 SDs below the mean for that gestation. What should be done?

A	discuss amniocentesis to confirm fetal infection
B	discuss with the local virologist
C	offer TOP
D	refer to a fetal medicine specialist
E	screen the mother for recent Zika infection
F	none of the above

Question 36.          

A pregnant woman with possible Zika exposure has an ultrasound scan showing significant brain abnormality. What further testing should be discussed?

A	amniocentesis + PCR
B	amniocentesis + RT-PCR
C	MR scan
D	Zika IgG
E	Zika IgG + IgM
F	Zika IgA + IgG + IgM
G	none of the above

43.         BRCA 1 & 2 carriers and risk of breast and ovarian cancer.

Abbreviations.

BCFR:       Breast Cancer Family Registry.

BSO:        bilateral salpingo-oophorectomy

EOC:        epithelial ovarian cancer

GHR:        Genetics Home Reference

HGSOG:  high-grade serous ovarian cancer

LGSOG:   low-grade serous ovarian cancer

SIP44:      RCOG’s Scientific Impact Paper No. 44, November 2014: “The Distal Fallopian Tube as the Origin of Non-Uterine Pelvic High-Grade Serous Carcinomas”.

SIP48:      RCOG’s Scientific Impact Paper No. 48. February 2015. “Management of Women with a Genetic Predisposition to Gynaecological Cancers.”

Scenario 1.

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

A	EOC is the most common gynaecological cancer in the developed world
B	EOC is the leading cause of death from gynaecological cancer in the developed world
C	50% of EOC is mucinoid
D	HGSOG is 20 times more common than LGSOG
E	HGSOG is the main cause of death from ovarian cancer
F	overall life time risk of EOC is 1 in 70
G	the main risk factors for EOC are cigarette smoking & older age
H	5% of ovarian cancer is due to identified hereditary genetic factors
I	BRCA1 is linked to an ↑ risk of breast, ovarian, pancreatic and prostate cancer
J	BRCA2 is linked to an ↑risk of breast, ovarian, pancreatic and prostate cancer & melanoma
K	The prevalence of BRCA1 & 2 mutations is about 1 in 400 in the general population
L	The prevalence of BRCA1 & 2 mutations is about 1 in 40 in the Ashkenazi Jewish population
M	The risk of developing ovarian cancer by 75 years is BRCA1: 50% and BRCA2: 25%
N	EOC associated with BRCA1 &2 is mostly low-grade mucinous in type
O	The risk of male breast cancer is about 7% with BRCA2, higher than with BRCA1
P	BRCA1 & 2 are DNA repair genes
Q	male breast, pancreatic and prostate cancer are more common with BRCA2 than BRCA1

Scenario 2.

A woman of 30 has two sisters who developed breast cancer before the age of 40. They and she have been proved to be carriers of BRCA1.

She attends the gynaecology clinic requesting information about her lifetime risk of breast cancer.

What is the approximate figure?

Scenario 3.

A woman of 30 has two sisters who developed breast cancer before the age of 40. They and she have been proved to be carriers of BRCA1.

She attends the gynaecology clinic requesting information about her lifetime risk of ovarian cancer.

What is the approximate figure?

Scenario 4.

A woman of 30 has two sisters who developed breast cancer before the age of 40. They and she have been proved to be carriers of BRCA2.

She attends the gynaecology clinic requesting information about her lifetime risk of breast cancer.

What is the approximate figure?

Scenario 5.

A woman of 30 has two sisters who developed breast cancer before the age of 40. They and she have been proved to be carriers of BRCA2.

She attends the gynaecology clinic requesting information about her lifetime risk of ovarian cancer.

What is the approximate figure?

Scenario 6.

The woman asks for the overall figure for lifetime risk of breast cancer in UK women for comparison with her risk.

What is the approximate figure?

Scenario 7.

The woman asks for the overall UK figure for lifetime risk of ovarian cancer for comparison with her risk.

What is the approximate figure?

Scenario 8

Which of the following genes have mutations that increase the risk of breast cancer?

Answer.

A	ATM
B	CDH1
C	CHEK1
D	FATHEAD
E	MARBELLA.
F	NBENE
G	p45
H	p53.
I	PALB2
J	PNINE
K	PTEN
L	RADON50
M	RINT1

Scenario 9

A man of 30 has two sisters who developed breast cancer before the age of 40. They and he have been proved to be carriers of BRCA2.

His GP phones to ask about his lifetime risk of breast cancer. What is the approximate figure?

Scenario 10

A man of 30 has two sisters who developed breast cancer before the age of 40. They and he have been proved to be carriers of BRCA2.

His GP phones to ask about his lifetime risk of ovarian cancer. What is the approximate figure?

Scenario 11

A woman of 30 has two sisters who developed breast cancer before the age of 40. They and she have been proved to be carriers of BRCA2.

She attends the gynaecology clinic requesting information about the value of prophylactic mastectomy. What advice will you give about efficacy?

Scenario 12

A woman of 30 has two sisters who developed breast cancer before the age of 40. They and she have been proved to be carriers of BRCA2.

She attends the gynaecology clinic requesting information about the benefits of prophylactic salpingo-oophorectomy – her family is complete and her husband has had vasectomy. What is the approximate figure for the efficacy of BSO in relation to cancer?

Scenario 13.

Which, if any, of the following statements is true in relation to the findings by Kuchenbaecker in relation to the incidence of breast cancer in carriers of a BRCA1 mutation?

Pick one option from the option list.

Option list.

A.	it rises rapidly until the age of 30-40, then stays constant until age 80
B.	it rises rapidly from puberty until the age of 30-40, then stays constant until age 80
C.	it rises rapidly from young adulthood until the age of 30-40, then stays constant until age 80
D.	it rises rapidly from puberty until the age of 40-50, then stays constant until age 80
E.	it rises rapidly from young adulthood until the age of 40-50, then stays constant until age 80
F.	it rises rapidly from puberty until the menopause, then stays constant until age 80
G.	it rises rapidly from young adulthood until the menopause, then stays constant until age 80
H.	none of the above

Scenario 14.

Which, if any, of the following statements is true in relation to the findings by Kuchenbaecker in relation to the incidence of breast cancer in carriers of a BRCA2 mutation?

Pick one option from the option list.

Option list.

A.	it rises rapidly until the age of 30-40, then stays constant until age 80
B.	it rises rapidly from puberty until the age of 30-40, then stays constant until age 80
C.	it rises rapidly from young adulthood until the age of 30-40, then stays constant until age 80
D.	it rises rapidly from puberty until the age of 40-50, then stays constant until age 80
E.	it rises rapidly from young adulthood until the age of 40-50, then stays constant until age 80
F.	it rises rapidly from puberty until the menopause, then stays constant until age 80
G.	it rises rapidly from young adulthood until the menopause, then stays constant until age 80
H.	none of the above

Scenario 15.

A woman of 30 has two sisters who developed breast cancer before the age of 40. They and she have been proved to be carriers of BRCA1.

She attends the gynaecology clinic requesting information about the benefits of prophylactic salpingo-oophorectomy. What are the disadvantages of BSO?

Scenario 16

A woman of 30 has two sisters who developed breast cancer before the age of 40. They and she have been proved to be carriers of BRCA1.

She attends the gynaecology clinic requesting information about the benefits of prophylactic salpingo-oophorectomy.  What alternatives should be discussed?

Scenario 17

A woman of 25 years is a known carrier of BRCA1. She has no family history of breast cancer. She has a friend who is similar in age and has similar risk factors for breast cancer, including being a BRCA1 carrier, apart from having two 1^st. degree relatives with breast cancer. Which, if any of the following statements is true in relation to the risk of breast cancer for the friend compared with the woman?

A.	her risk is the same
B.	her risk is 2 x that of the woman
C.	her risk is 5x that of the woman
D.	her risk is ½ of that of the woman
E.	none  of the above

Scenario 18

A woman of 25 years is a known carrier of BRCA2. She has no family history of breast cancer. She has a friend who is similar in age and has similar risk factors for breast cancer, including being a BRCA2 carrier, apart from having two 1^st. degree relatives with breast cancer. Which, if any of the following statements is true in relation to the risk of breast cancer for the friend compared with the woman?

A.	her risk is the same
B.	her risk is 2 x that of the woman
C.	her risk is 5x that of the woman
D.	her risk is ½ of that of the woman
E.	none  of the above

44.         EMQ. Staging of cervical cancer.

Option list.

1.         Micro-invasive cervical cancer.

2.         Stage Ia1

3.         Stage Ia2

4.         Stage Ia3

5.         Stage Ib1

6.         Stage Ib2

7.         Stage Ib3

8.         Stage IIa

9.         Stage IIb

10.     Stage IIc

11.     Stage IIIa

12.     Stage IIIb

13.     Stage IIIc

14.     Stage IVa

15.     Stage IVb

16.     Stage IVc

17.     Stage Va

18.     Stage Vb

19.     Stage Vc

20.     None of the above.

Scenario 1.

A woman of 25 has a cone biopsy. The histology report shows squamous cell carcinoma penetrating to a depth of 2 mm and 6 mm in width. The resection margins are tumour-free. There is no evidence of spread outside the uterus. She is nulliparous and wishes to retain her fertility.

Scenario 2.

A woman of 25 has a cone biopsy. The histology report shows squamous cell carcinoma penetrating to a depth of 5 mm and 6 mm in width. The resection margins are tumour-free. There is no evidence of spread outside the uterus. She is nulliparous and wishes to retain her fertility.

Scenario 3.

A woman of 25 has a cone biopsy. The histology report shows squamous cell carcinoma penetrating to a depth of 5 mm and 6 mm in width. The resection margins are not tumour-free. There is no evidence of spread outside the uterus. She is nulliparous and wishes to retain her fertility.

Scenario 4.

A woman of 25 has a cone biopsy. The histology report shows squamous cell carcinoma penetrating to a depth of 6 mm and 3 cm in width. The resection margins are tumour-free. There is no evidence of extension outside the uterus. She is nulliparous and wishes to retain her fertility.

Scenario 5.

A woman of 25 has a cone biopsy. The histology report shows squamous cell carcinoma penetrating to a depth of 6 mm and 5 cm in width. The resection margins are tumour-free. She is nulliparous and wishes to retain her fertility.

Scenario 6.

A woman of 38 has a cone biopsy. The histology report shows squamous cell carcinoma penetrating to a depth of 4 mm and 6mm in width. The resection margins are tumour-free. An MR scan shows involvement of the lymphatic nodes in the left of the pelvis.

Scenario 7.

A woman of 45 has carcinoma of the cervix. It extends into the parametrium, but not to the pelvic side-wall. It involves the upper 1/3 of the vagina. There is MR evidence of para-aortic node involvement.

Scenario 8.

A woman of 55 has carcinoma of the cervix. It extends to the pelvic side-wall. It involves the upper 1/3 of the vagina. She has a secondary on the end of her nose.

Scenario 9.

A woman of 55 has carcinoma of the cervix. It involves the bladder mucosa.

Scenario 10.

A woman of 35 has a proven cancer of the cervix with extension into the right parametrium, but not to the pelvic side-wall. Left hydroureter and left non-functioning kidney are noted on IVP and there is no other explanation for the findings. Cystoscopy shows bullous oedema of the bladder mucosa.

Scenario 11.

A woman of 25 has a cone biopsy. It shows malignant melanoma. The lesion invades to a depth of 3 mm and is 5 mm in width. The margins of the biopsy are clear. There is evidence of lymphatic vessel involvement. There is no evidence of spread outside the uterus.