16th. May 2022

 

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1	How to prepare. Part 2. What to read. StratOG. TOG CPD. RCOG sample questions. Revision system. Study buddies. Intelligent guessing. Statistics. Urogynae. Other specialist tutorials.
2	EMQ. Relugolix.
3	EMQ. Hepatitis B
4	EMQ. Hepatitis D
5	EMQ. Mycoplasma Genitalium

 

1.     How to prepare for Part 2.

 

2.     Relugolix and fibroids.

Abbreviations.

DEXA:           dual-energy x-ray absorptiometry for bone density.

RON:             relugolix + oestradiol + norethisterone

Question 1.  Which, if any, of the following are correct about relugolix?

Option list.

A	it is a FSH agonist
B	it is a FSH antagonist
C	it is a GnRH agonist
D	it is a GnRH antagonist
E	is an oestrogen receptor modulator
F	is a progestogen receptor modulator

Question 2.             Which, if any, of the following are true about the preparation recommended by NICE for the use of relugolix in gynaecology?

Option list.

A	it contains relugolix as the only active component
B	it contains relugolix and ibuprofen
C	it contains relugolix with ethinylestradiol and desogestrel
D	it contains relugolix with oestradiol and norethisterone
E	it is administered intramuscularly
F	it is administered orally
G	it is administered nasally as a spray
H	it is administered subcutaneously
I	it is administered daily
J	it is administered monthly
K	it is administered three-monthly
L	it is in the form of a rod which can be removed easily
M	the proprietary preparation in called ‘Ryegg’
N	the proprietary preparation in called ‘Ryego’
O	the proprietary preparation in called  ‘Wryegg’
P	the proprietary preparation in called ‘Wryego’

Question 3.            Which, if any, of the following were described by NICE as proven benefits from the use of RON?

Option list.

A	↓ menstrual bleeding compared with GnRH agonists
B	↓ menstrual bleeding compared with placebo
C	↓ size of fibroids compared with  GnRH agonists
D	↓ size of fibroids compared with  placebo
E	↓ rate of expulsion of submucous fibroids compared with GnRH agonists
F	↓ rate of expulsion of submucous fibroids compared with placebo

Question 4.            Which, if any, of the following are described by NICE as likely benefits from the use of relugolix preparation available in the UK?

Option list.

A	is effective long-term
B	is safe long-term
C	is well-tolerated
D	has no adverse effect on fertility
E	↓ the risk of breast cancer
F	↓ the risk of cervical cancer
G	↓ the risk of endometrial cancer

Question 5.            For which of the following is the UK relugolix preparation licensed?

Option list.

A	breast cancer
B	cervical cancer
C	endometrial cancer
D	ovarian cancer
E	prostate cancer
F	endometriosis
G	fibroids
H	premenstrual syndrome
I	puerperal psychosis

Question 6.             

Which, if any, of the following are listed as contraindications to the use of the relugolix preparation available in the UK?

Option list.

A	asthma
B	breast cancer
C	breastfeeding
D	osteoporosis
E	protein C deficiency
F	von Willebrand’s disease

Question 7.            Which, if any, of the following are listed as side-effects by the manufacturer?

Option list.

A	acne
B	alopecia
C	angina
D	anxiety
E	asthma
F	breast cysts
G	breast pain
H	depression
I	dyspepsia
J	expulsion of fibroid
K	hot flushes
L	hyperhidrosis
M	night sweats
N	red degeneration of fibroid
O	reduced libido
P	uterine bleeding

Question 8.             

Which, if any, of the following are correct in relation to long-term contraception while taking RON?

Option list.

A	barrier methods are recommended
B	depot and implant progestogens are recommended
C	IUDs are recommended
D	combined oral contraception is contraindicated
E	RON provides adequate contraception, but additional contraception should be used for 3/12
F	RON may delay recognition of an unplanned pregnancy

Question 9.            Which, if any, of the following are advised prior to prescribing RON?

Option list.

A	clotting screen
B	DEXA scan
C	endometrial histology
D	full blood count
E	liver function tests
F	pregnancy test
G	thyroid function tests

Question 10.        Which, if any, of the following are true in relation to the potential for the preparation available in the UK to react adversely with other drugs?

Option list.

A	use with P-glycoprotein inhibitors is not recommended
B	use with CYP3A4 inducers in not recommended
C	use with penicillin in not recommended
D	use with aspirin is not recommended
E	use with St John’s wort is not recommended

Question 11.        What advice should be given after missed pills?

Option list.

A	non-hormonal contraception for 7   days after  1 missed pill
B	non-hormonal contraception for 10 days after  1 missed pill
C	non-hormonal contraception for 14 days after  1 missed pill
D	non-hormonal contraception for 7   days after  2 consecutive missed pills
E	non-hormonal contraception for 10 days after  2 consecutive missed pills
F	non-hormonal contraception for 14 days after  2 consecutive missed pills
G	non-hormonal contraception for 7   days after  ≥ 3 consecutive missed pills
H	non-hormonal contraception for 10 days after  ≥ 3  consecutive missed pills
I	non-hormonal contraception for 14 days after  ≥ 3  consecutive missed pills

 

3.     Hepatitis B and pregnancy.

Abbreviations.

GDM:         gestational diabetes mellitus.

HAV:           hepatitis A virus

HBcAg:       hepatitis B core antigen

HBeAg:       hepatitis B e antigen

HBsAg:       hepatitis B surface antigen

HBcAb:       antibody to hepatitis B core antigen

HBeAb:      antibody to hepatitis B e antigen

HBsAb:       antibody to hepatitis B surface antigen

HBIG:         hepatitis B immunoglobulin

HBV:           hepatitis B virus

HBcAg:       hepatitis B core antigen

HBeAg:       hepatitis B e antigen

HBsAg:       hepatitis B surface antigen

HBcAb:       antibody to hepatitis B core antigen

HBeAb:      antibody to hepatitis B e antigen

HBsAb:       antibody to hepatitis B surface antigen

HBIG:         hepatitis B immunoglobulin

HCV:           hepatitis C virus

HEV:           hepatitis E virus

HSV:           herpes simplex virus

VT:              vertical transmission

Question 1.           An asymptomatic primigravida books at 10 weeks. Her partner had an acute HBV infection 4 months ago. What results on routine blood testing would indicate that she has an acute HBV infection?

Question 2.           An asymptomatic primigravida books at 10 weeks. Her partner had an acute HBV infection 4 months ago. What results on routine blood testing would indicate that she is immune to the HBV as a result of infection?

Question 3.           An asymptomatic primigravida books at 10 weeks. Her partner had an acute HBV infection 4 months ago. What results on routine blood testing would indicate that she is immune to the HBV as a result of HBV vaccine?

Question 4.           An asymptomatic primigravida books at 10 weeks. Her partner had an acute HBV infection 9 months ago. What results on routine blood testing would show that she is a chronic carrier of HBV infection?

Question 5.           Testing shows that he is positive for HBsAg, positive for HBcAb but negative for IgM HBcAb. What does this mean in relation to his HBV status?

Question 6.           Testing shows that he is negative for HBsAg, positive for HBcAb and positive for HBsAb. What does this mean in relation to his HBV status?

Question 7.           How common is chronic HBV carrier status in UK pregnant women?

Question 8.           What is the risk of death from chronic HBV carrier status?

Question 9.           A primigravid woman at 8 weeks gestation is found to be non-immune to HBV. She has recently married and her husband is a chronic carrier. What should be done to protect her from infection?

Question 10.        A woman is a known carrier of HBV. What is the risk of vertical transmission in the first trimester?

Question 11.        What is the risk of the neonate who has been infected by vertical transmission becoming a carrier without treatment?

Question 12.        Should antiviral maternal therapy in the 3^rd. trimester be considered for women with HBeAg or high viral load?

Question 13.        How effective is hepatitis B prophylaxis for the neonate in preventing chronic carrier status as a result of vertical transmission?

Question 14.        Can a woman who is a chronic HBV carrier breastfeed safely?

Question 15.        Is Hepatitis B infection the most dangerous of the viral hepatitis infections in pregnancy?

Question 16.        A pregnant woman who is not immune to HBV has a partner who is a chronic carrier. Can HBV vaccine be administered safely in pregnancy?

Question 17.        How long can HBV survive outside the body?

Question 18.        A pregnant woman who is not immune has a partner with acute hepatitis due to HBV. He cuts his hand and bleeds onto the kitchen table. How should she clean the surface to ensure that she gets rid of the virus?

Question 19.        Is it true that the presence of HBeAg in maternal blood is a particular risk factor for vertical transmission? Not really a scenario, but never mind!

Question 20.        What does 5 log10 copies /mL mean?

A	> 10 copies / mL
B	> 100 copies / mL
C	> 1,000 copies / mL
D	> 10,000 copies / mL
E	> 100,000 copies / mL
F	this has scared me witless and I am going straight home to complain to my Mum

Question 21.        Which, if any, of the following statements are true about amniocentesis and CVS and the risk of vertical transmission if the mother is HbsAg+ve?

Option list.

A	they are contraindicated
B	they should be done with cover with HBIG
C	they should be done with cover with a drug that is  effective for HBV and safe in pregnancy.
D	none of the above

Question 22.         

Which, if any, of the following statements are true about treatment in the third trimester to reduce the risk of vertical transmission?

Option list.

A	women who are HbsAg+ve should be offered testing for HBV DNA levels in the 3rd. trimester
B	there is no effective treatment for HBV in the 3rd. trimester
C	the risks of treatment for HBV in the 3rd. trimester outweigh the benefits
D	drug treatment for HBV in the 3rd. trimester adds nothing beneficial to the normal use of HBIG + HB vaccination of the neonate
E	none of the above.

Question 23.         

Which, if any, of the following drugs is recommended for use in the third trimester to reduce the risk of vertical transmission?

Option list.

A	acyclovir
B	lamivudine
C	telbivudine
D	tenofovir

Question 24.         

Does elective Cs before labour and with the membranes intact reduce the vertical transmission rate?

Question 25.        Which hepatitis virus normally produces a mild illness, but represents a major risk to pregnant women, with a mortality rate of up to 5%?

Question 26.        A pregnant woman has a history of viral hepatitis and informs the midwife at booking that she is a carrier and that she has a significant risk of cirrhosis and has been advised not to drink alcohol. Which is the most likely hepatitis virus?

Question 27.        Which hepatitis virus is an absolute contraindication to breastfeeding after appropriate treatment of the infected mother and prophylaxis for the baby?

Question 28.        Which hepatitis virus is linked to an increased risk of obstetric cholestasis?

Question 29.        Which, if any, of the following statements is true in relation to HepB and the risk of GDM?

Option list.

A	the risk is about the same
B	the relative risk is about 0.1.
C	the relative risk is about 0.2.
D	the relative risk is about 0.5.
E	the relative risk is about 1.2.
F	the relative risk is about 1.5.
G	the relative risk is about 2.0
H	the relative risk is about 3.0
I	the risk is unknown

 

4.     Hepatitis D. Hepatitis Delta.

Abbreviations:

HBsAg:       hepatitis B surface antigen

HBsAb:       antibody to hepatitis B surface antigen

HBV:           hepatitis B virus

HCsAg:       hepatitis C surface antigen

HDV:          hepatitis D virus; hepatitis delta virus

HEsAg:       hepatitis E surface antigen

Question 1.   Which, if any, of the following statements are true in relation to HDV? This is not a true EMQ as there may be >1 correct answer.

Option list.

A	HDV is a large DNA virus
B	HDV is a defective virus
C	HDV gains entry to human cells via the HDV receptor
D	HDV gains entry to human cells by donning a disguise and using the HBV receptor
E	HDV only flourishes when HBsAb is present
F	HDV only flourishes when HbsAg is present
G	Co    coinfection is when HDV and another viral infection are present at the same time
H	Sususuperinfection is when HDV is present in abnormally high numbers
I	HDV infection is the least serious of the viral hepatitides in relation to pregnancy
J	HDV treatment was revolutionised by analysis of the benefits of drinking bleach as suggested by Donald Trump
K	the   WHO has recommended that those who follow medical advice from Donald trump should be categorised as ‘having the DTs’.
L	HDV needs the presence of HBsAg to be a significant pathogen
M	HDV needs the presence of HCsAg to be a significant pathogen
N	HDV needs the presence of HEsAg to be a significant pathogen
O	p       pegylated interferon alpha is highly effective as treatment
P	m      mother-to-child transmission is mainly via the placenta
Q	WHO recommends tenofovir prophylaxis from 28 weeks in pregnancy in HDV infected women
R	the   infected neonates should be given HDV vaccine

 

5.           Mycoplasma genitalium. .

BASSH launched a new, “NICE-accredited” guideline on MG in July 2018 This makes it a hot topic and it is one that most people will know nothing about. There are enough “buzz words” to catch the attention of MRCOG examiner sand make its inclusion in the exam databases irresistible! It would be a killer “structured discussion” in the Part 3 and would sink most candidates in the Part 2.

Many of the questions are not true EMQs as they have more than one correct answer. I have tried to include all the facts I think might feature in the exam and packing more than one into a question reduces the total number of questions and makes the document a bit more manageable. It also reduces the amount of typing I have to do.

Abbreviations.

BASHHMG:  British Association for Sexual Health and HIV’s “National guideline for the management of infection with Mycoplasma genitalium”. 2018

NHSCS:         NHS Cervical Screening Programme

Scenario 1.        Which, if any, of the following statements are true in relation to MG? This is not a true EMQ as there may be more than one correct answer.

Option list.

A	MG was first isolated in 2001
B	MG was first isolated from men with non-gonococcal urethritis (NGU)
C	MG belongs to the Cutemollies class
D	MG is the smallest known yeast with the ability to self-replicate
E	MG is the smallest known bacterium with the ability to self-replicate
F	MG has an unusual, double-layered cell wall
G	MG has an unusual protrusion at one end
H	MG’s protrusion enables it to adhere to epithelial cells
I	MG’s protrusion enables it to invade epithelial cells
J	MG is best seen on a Gram stain

Scenario 2.        Which, if any, of the following statements are true in relation to Mycoplasmas?

Option list.

A	are the largest known bacteria
B	have no cell wall
C	have no nuclei
D	are resistant to ß-lactam antibiotics
E	are resistant to sulphonamides
F	colonies show a ‘scrambled egg’ appearance on culture on agar
G	particularly affect mucosal surfaces

Scenario 3.        Which, if any, of the following statements are true in relation to Mg?

Option list.

A	when the organism was originally found, culture took 50 days
B	Mg is facetious
C	Mg is a facultative aerobe
D	Mg is a facultative anaerobe
E	Mg is a facultative aerobe & anaerobe
F	Mg is fastidious

Scenario 4.        Which, if any, of the following are true in relation to the approximate prevalence of MG?

Option list.

A	it is ~ 0.1%
B	it is ~ 1.0%
C	it is ~ 5.0%
D	it is ~ 5-10%
E	it is > 10%
F	none of the above

Scenario 5.        Which, if any, of the following is true in relation to screening for MG? This is a true EMQ with only one correct answer.

Option list.

A	screening for MG is now included in the NCSP
B	screening for MG is now offered as part of the NHSCS
C	screening should be offered to all sexually active women < 30 years old
D	screening should only be offered to those with symptoms suggestive of infection
E	screening should be offered to all partners of those with MG infection
F	none of the above

Scenario 6.              

Which, if any, of the following are included in BASHHMG as risk factors for infection with MG?

Option list.

A	Cigarette smoking
B	Multiple dancing partners
C	Multiple sexual partners
D	Non-white ethnicity
E	Younger age
F	None of the above

Scenario 7.        Which of the following statements is true in relation to MG and co-infection with other organisms?

Option list.

A	MG excretes bactericidal toxins and co-infection is rare
B	MG co-infection is most often with chlamydia
C	MG co-infection is most often with E. coli
D	MG co-infection is most often with HIV
E	MG co-infection is most often with TB
F	None of the above

Scenario 8.        Which of the following statements is true in relation to MG and men?

Option list.

A	It is the most common cause of NGU
B	It is the most common cause of epididymitis
C	It is the most common cause of prostatitis
D	It is a well-recognised cause of male sub-fertility
E	Most men with MG infection are asymptomatic
E	None of the above

Scenario 9.        Which, if any, of the following statements are true in relation to MG and women?

Option list.

A	MG is linked to an ↑ risk of cervicitis
B	MG is linked to an ↑ risk of endometritis
C	MG is linked to an ↑ risk of female infertility
D	MG is linked to an ↑ risk of miscarriage
E	MG is linked to an ↑ risk of otitis media
F	MG is linked to an ↑ risk of pelvic inflammatory disease
G	MG is linked to an ↑ risk of postcoital bleeding
H	MG is linked to an ↑ risk of postmenopausal bleeding
I	MG is linked to an ↑ risk of preterm birth
J	MG is linked to an ↑ risk of damage to Fallopian tube cilia
K	MG is linked to an ↑ risk of puerperal psychosis
L	MG is linked to an ↑ risk of puerperal sepsis
M	Most infected women are asymptomatic
N	None of the above

Scenario 10.      Which, if any, of the following statements are true in relation to current concerns about Mg?

Option list.

A	It could become a ‘superbug’, resistant to most antibiotics, within a decade
B	Infection is often misdiagnosed as chlamydia with ↑ risk of antibiotic resistance
C	‘superbug’ status would be likely to lead to an ↑ in renal failure
D	‘superbug’ status would be likely to lead to an ↑ in female infertility
E	‘superbug’ status would be likely to lead to an ↑ in male infertility

Scenario 11.     Which, if any, of the following are used in the recommended test for MG infection in women?

Option list.

A	blood testing for MG IgG
B	blood testing for MG IgM
C	cervical smears checked microscopically for the diagnostic intracellular inclusion bodies
D	culture and sensitivity of cervical swab specimens using MG-specific culture medium
E	culture and sensitivity of 1st. void MSSU using MG-specific culture medium
F	culture and sensitivity of vaginal swab specimens using MG-specific culture medium
G	NAATs that detect the MG G-antigen
H	NAATs that detect MG DNA
I	NAATs that detect MG RNA
J	serum testing for MG-specific antigen
K	vaginal swabs taken by the woman
L	none of the above

Scenario 12.     Which, if any, of the following statements are true in relation to testing for antibiotic resistance after initial tests are +ve for MG?

Option list.

A	test for resistance to cephalosporins
B	test for resistance to macrolides
C	test for resistance to penicillin
D	test for resistance to quinolones
E	test for resistance to macrolides
F	test for resistance to streptomycin
F	test for resistance to sulphonamides
F	test for resistance to tetracyclines
G	None of the above

Scenario 13.     Which, if any, of the following statements are true in relation to estimates of antibiotic resistance in current strains of MG in the UK?

Option list.

A	20% are resistant to cephalosporins
B	40% are resistant to macrolides
C	50% are resistant to penicillin
D	50% are resistant to quinolones
E	10% are resistant to streptomycin
F	90% are resistant to sulphonamides
F	40% are resistant to tetracyclines
F	None of the above

Scenario 14.     Which, if any, of the following is BASHHMG’s recommended 1^st. line treatment of uncomplicated MG?

Option list.

A	azithromycin 1 gram daily for 7 days
B	doxycycline 100 mg twice daily for 7 days
C	doxycycline 100 mg twice daily for 10 days
D	doxycycline 100 mg twice daily for 7 days
E	doxycycline 100 mg twice daily for 7 days then azithromycin 1 gram daily for 2 days
F	moxifloxacin 400mg orally once daily for 7 days
G	moxifloxacin 400mg orally once daily for 10 days
H	none of the above

Scenario 15.     Which, if any, of the following is BASHHMG’s recommended 1^st. line treatment of complicated MG?

Option list.

A	doxycycline 100 mg twice daily for 10 days
B	doxycycline 100 mg twice daily for 14 days
C	moxifloxacin 400mg orally once daily for 10 days
D	moxifloxacin 400mg orally once daily for 14 days
E	none of the above

Scenario 16.     This is not an EMQ or SBA! Fill in the gaps in the table below, using option list.

Option list.

A	aminoglycoside
B	cephalosporin
C	macrolide
D	penicillin
E	quinolone
F	tetracycline

Table.

Drug name	Category of drug
azithromycin
doxycycline
moxifloxacin

Scenario 17.     Which, if any, of the following statements is true in relation to test of cure (TOC) after treatment of MG?

Option list.

A	TOC should be offered to everyone who has been treated for MG
B	TOC should only be offered to those who had signs of infection before treatment
C	TOC should only be offered to those who had symptoms of infection before treatment
D	TOC should only be offered to those who had signs and symptoms before treatment
E	TOC should only be offered to those who continue to have signs or symptoms two weeks or more after the start of treatment
F	none of the above

Scenario 18.     Which, if any, of the following statements are true in relation to the timing of test of cure (TOC) after treatment of MG?

Option list.

A	TOC is best done at 3 weeks after start of treatment
B	TOC is best done at 4 weeks after start of treatment
C	TOC is best done at 5 weeks after start of treatment
D	TOC is best done at 6 weeks after start of treatment
E	TOC should not be done < 2 weeks from the start of treatment
F	TOC should not be done < 3 weeks from the start of treatment
G	TOC should not be done < 4 weeks from the start of treatment