Tutorial 17 November 2022

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7	Role-play. Woman attends for pre-pregnancy counselling as she plans her 1st. pregnancy.
8	EMQ. Hepatitis C and pregnancy. HCV
9	EMQ. Medical examiner system
10	EMQ. Gestational trophoblastic disease
11	EMQ. Kallmann’s syndrome
12	SBA. Fetal origins of adult disease

 

7.           Role-play. Prepregnancy counselling.

Candidate’s instructions.

You are the SpR in the gynaecology clinic. You have been asked to see Jenny Williams, who has come for pre-pregnancy counselling.

Letter from the General Practitioner.

5 High Street,

Deersworthy,

Kent.

DO9 1JY.

Re Mrs. J. Williams,

Manor Place,

Deersworthy.

 

Dear Dr.,

Please see this woman who is planning pregnancy. I understand that her sister has had a baby with Down’s syndrome. I have explained that this increases her risk of having a similarly-affected baby to a significant degree.

Regards,

Dr. Jolly.

 

8.           EMQ. Hepatitis C and pregnancy.

Abbreviations.

DAAD:           Direct-acting, antiviral drug.

HBV:              Hepatitis B virus.

HCV:              Hepatitis C virus.

HCAb:           Hepatitis C antibody.

ROM:            Rupture of membranes.

Scenario 1.         Which, if any, of the following statements are true?

Option list.

A	Hepatitis kills more people world-wide than HIV
B	Hepatitis kills more people world-wide than TB
C	Hepatitis B kills more people world-wide that Hepatitis C
D	Hepatitis B kills more people world-wide than TB
E	None of the above

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

Option list.

A	It is a DNA virus
B	It is a RNA virus
C	It is a member of the Flaviviridae family
D	it is a member of the Hepadnaviridae family
E	it is a member of the Herpesviridae family
F	most infections are due to genotypes 1 & 3
G	most infections are due to genotypes 2 & 4

Scenario 3.         What is the approximate prevalence of HCV infection in the UK?

Option list.

A	0.1 per 1,000
B	0.3 per 1,000
C	0.5 per 1,000
D	1 per 1,000
E	3 per 1,000
F	5 per 1,000
G	10 per 1,000
H	13 per 1,000
I	15 per 1,000
J	None of the above

Scenario 4.         What are the key aspects of the WHO’s Global Health Sector Strategy in relation to

HCV infection?

Option list.

A	elimination as a as a major public health threat by 2020
B	elimination as a as a major public health threat by 2030
C	elimination as a as a major public health threat by 2040
D	reduction in incidence by 50% by 2030
E	reduction in incidence by 75% by 2030
F	reduction in incidence by 80% by 2030
G	reduction in mortality by 50% by 2030
H	reduction in mortality by 65% by 2030
I	reduction in mortality by 70% by 2030

Scenario 5.         What is the incubation period of HCV infection?

Option list.

A	6 weeks
B	2 months
C	up to 3 months
D	up to 4 months
E	up to 6 months
F	up to 12 months
G	none of the above

Scenario 6.         What symptoms are most common in acute HCV infection? There is no option list.

Scenario 7.         How is acute HCV infection diagnosed?

Option list.

A	clinically
B	presence of HCV antibody
C	presence of HCV RNA
D	none of the above

Scenario 8.         What proportion of those with acute HCV infection are asymptomatic?

Option list.

A	10%
B	20%
C	50%
D	60%
D	70%
E	> 80%

Scenario 9.         When does continuing infection after initial exposure become defined as chronic

infection?

Option list.

A	after 6 weeks
B	after 2 months
C	after 3 months
D	after 4 months
E	after 6 months
F	after 12 months
G	none of the above

Answer. E. After 6 months.

Scenario 10.      Approximately how many of those with acute HCV infection will go on to chronic

infection?

Option list.

A	10%
B	20%
C	40%
D	50%
E	>50%
F	>70%

Scenario 11.      A woman is found to have HCV antibodies. Which, if any, of the following statements

could be true?

Option list.

A	she could have acute HCV infection
B	she could have chronic infection
C	she could have had HCV infection that has cleared spontaneously
D	she could have had HCV infection that has responded to drug therapy
E	she could have a false +ve test result
F	she could have chronic HBV infection due to cross reaction with HBcAg
G	she is immune to HCV
H	the antibodies could result from HCV vaccine
I	the antibodies could result from yellow fever vaccine
J	none of the above

Scenario 12.      Which, if any, of the following statements reflect current thinking about the

mechanisms of damage in chronic HCV infection?

Option list.

A	hepatic damage is proportional to the duration of HCV infection
B	hepatic damage is a direct result of HCV replication within hepatocytes
C	hepatic damage is proportional to the level of detectable HCV RNA in maternal blood
D	hepatic damage is immune-mediated
E	hepatic damage is due to progressive biliary tract infection, scarring  and stenosis
F	hepatic damage mostly occurs in women who abuse alcohol
G	hepatic damage is worse in women with co-existing HIV infection
H	hepatitis D is end-stage hepatitis C, with cirrhosis and liver failure, ‘D’ originating from the original name: ‘deadly-stage’ HCV disease

Scenario 13.      How common is vertical transmission? There is no option list.

Scenario 14.      Which, if any, of the following statements are true in relation to the hepatitides?.

A	acute hepatitis is notifiable
B	chronic hepatitis is notifiable
C	hepatitis A is notifiable as the main route of spread is faecal contamination of food & water
D	hepatitis D is notifiable as the main source of infection is infected food and water
E	hepatitis E is notifiable as the main source of infection in the UK is raw or undercooked pork
F	none of the above

Scenario 15.      What anti-viral treatment is recommended for pregnancy? There is no option list.

Scenario 16.      Which, if any, of the following are true about Ribavirin?

Option list.

A	it is the least expensive of the new DAADs for HCV
B	it is the least toxic of the new DAADs for HCV
C	it is the most effective of the new DAADs for HCV
D	it is contraindicated in pregnancy because of fears of teratogenicity
E	can cause sperm abnormalities
F.	can persist in humans for up to 6 months
G.	none of the above

Scenario 17.      A woman with chronic HCV wishes to breastfeed. What advice would you give? There is no option list.

Scenario 18.      How is neonatal infection diagnosed? There is no option list.

Scenario 19.      How is neonatal infection treated? There is no option list.

Scenario 20.      Which, if any, of the following conditions is more common in women with HCV infection?

Option list.

A	dermatitis herpetiformis
B	HELLP syndrome
C	obstetric cholestasis
D	postnatal depression
E	thrombocytopenia

Scenario 21.      By how much is the risk of the condition in question 20 increased in women with HCV?

Option list.

A	by a factor of 2
B	by a factor of 5
C	by a factor of 20
D	by a factor of 50
E	none of the above

Scenario 22.      Which, if any, of the following statements is true about HCV and the Nobel Prize?

Option list.

A	the Nobel Prize was awarded to Alter, Houghton & Rice in 2020
B	the Nobel Prize was awarded to Alter, Hogg & Rice in 2020
C	the Nobel Prize was awarded to Alter, Houghton & Rees in 2020
D	the Nobel Prize was awarded to Change, Houghton & Rice in 2020
E	the Nobel Prize was awarded to Change, Hogg & Rice in 2020
F	the Nobel Prize was awarded to Change, Hogg & Barleycorn in 2020
G	the Nobel Prize has not been awarded for work on HCV

 

9.           EMQ. Medical examiner system.

Abbreviations.

MCCD:          medical certificate of the cause of death.

ME:               medical examiner.

Do I really need to know this stuff? This is ‘hot’: MEs were an innovation in 2018.

Question 1.        Which, if any, of the following are included in the role of the ME?

Option list.

A	scrutiny of all death certificates from the NHS Trust
B	scrutiny of all death certificates from the local area
C	scrutiny of non-coronial death certificates from the local area
D	deciding if postmortem examination is appropriate
E	supervision of postmortem examination
F	deciding on and arranging further investigations to establish the cause of death
G	liaison with the coroner
H	discussing the cause of death with the family of the deceased
I	directing police investigations in cases of suspicious death

Question 2.        What qualifications must a ME have?

Option list.

A	be registered with the GMC
B	be licensed to practise or be < 5 years into retirement
C	be a member or fellow of a Royal Medical College
D	be a member or fellow of the Royal College of Pathologists
E	none of the above.

Question 3.        Which, if any, of the following are included in the role of the medical examiner?

Option list.

A	discussing the case with the doctor who provided care during the final illness
B	reviewing the medical records
C	deciding the cause of death to be put on the certificate of death
D	discussing the cause of death with next of kin
E	identifying any concerns the next of kin may have about the care
F	providing medical advice to the coroner
G	identifying deaths that should trigger a mortality case record review

Question 4.        Which, if any, of the following are included in the role of the National ME?

Option list.

A	being a member of the medical team responsible for the Queen’s health
B	appointing Trust MEs
C	disciplining errant MEs
D	producing reports
E	arbitrating in disputes between MEs and coroners about the cause of death
F	dealing with appeals by families who are dissatisfied with the MCCD or the care

 

10.         EMQ. Gestational trophoblastic disease.

Abbreviations.

CHM:            complete hydatidiform mole.

EPT:               epithelioid tumour.

GI:                 gastro-intestinal.

GTD:              gestational trophoblastic disease.

GTDTC:         gestational trophoblastic disease treatment centre.

GTN:              Gestational trophoblastic neoplasia.

HM:               hydatidiform mole.

PHM:             partial hydatidiform mole.

POC:              products of conception.

PSTT:             placental site trophoblastic tumour.

Option list.

A	100%.
B	20%.
C	15%.
D	10%.
E	5%.
F	2.5%.
G	1.5%.
H	0.5%.
I	1 in 35.
J	1 in 55.
K	1 in 65.
L	1 in 700.
M	1 in 1,000.
N	Ö64.
O	pr2.
P	increased.
Q	reduced.
R	increased by a factor of 2.
S	increased by a factor of 5.
T	increased by a factor of 10.
U	increased by a factor of 20.
V	increased by a factor of 30.
W	increased by a factor of > 100.
X	hydatidiform mole, both partial and complete.
Y	hydatidiform mole, both partial and complete and placental site tumour.
Z	partial mole, complete mole, invasive and metastatic mole, choriocarcinoma, placental site trophoblastic tumour and epithelioid trophoblastic tumour.
AA	choriocarcinoma invasive and metastatic mole and epithelioid trophoblastic tumour.
BB	true
	false
	none of the above.

 

Scenario 1.         List the conditions included in the term GTD. There is no option list, just make a list.

Scenario 2.         What is the difference between GTD and GTN? Pick one option from the list below.

Option list.

A	GTD comprises the non-malignant conditions, i.e. complete and partial moles. GTN comprises the malignant conditions: invasive mole, choriocarcinoma and PSTT
B	GTD comprises all the trophoblastic conditions; GTN comprises the malignant conditions
C	GTD comprises all the trophoblastic conditions; GTN comprises persistent GTD
D	GTD comprises all the trophoblastic conditions; GTN comprises malignant and potentially malignant conditions, including atypical placental site nodules
E	none of the above

Scenario 3.         GTG38 mentions one thing as the minimum standard of care. What is it?

There is not option list as that would make it too easy.

Scenario 4.         What is the incidence of GTD in the UK?

Scenario 5.         Which , if any, of the following are true of complete moles?

A	are usually diploid and with all the chromosomal material of paternal origin
B	are usually triploid, with 2 sets of paternal haploid genes + 1 set of maternal haploid genes
C	are usually triploid, with 1 set of paternal haploid genes + 2 sets of maternal haploid genes
D	are tetraploid or mosaics in up to 10% of cases
E	up to 80% are due to duplication of a single sperm in an egg devoid of maternal chromosomes
F	up to 80% are due to duplication of a single sperm in a normal egg
G	usually result from dispermic fertilisation of a normal egg
H	usually result from dispermic fertilisation of an egg devoid of maternal chromosomes
I	usually has 46XX makeup
J	usually has 46XY makeup
K	the presence of fetal red blood cells defines a mole as partial
L	mitochondrial DNA is maternal
M	mitochondrial DNA is paternal

Scenario 6.         Which, if any, of the following are true of partial moles?

Option list.

A	are usually diploid and with paternal chromosomal material
B	are usually triploid, with 2 sets of paternal haploid genes + 1 set of maternal haploid genes
C	are usually triploid, with 1 set of paternal haploid genes + 2 sets of maternal haploid genes
D	are tetraploid or mosaics in up to 10% of cases
E	up to 80% are due to duplication of a single sperm in an egg devoid of maternal chromosomes
F	up to 80% are due to duplication of a single sperm in a normal egg
G	usually result from dispermic fertilisation of a normal egg
H	usually result from dispermic fertilisation of an egg devoid of maternal chromosomes
I	usually has 46XX makeup
J	usually has 46XY makeup
K	the presence of fetal red blood cells defines a mole as partial
L	mitochondrial DNA is maternal
M	mitochondrial DNA is paternal

Scenario 7.         What is the ratio of complete: partial moles?

Scenario 8.         What is the risk of molar pregnancy at age < 15 compared to age 30?

Scenario 9.         What is the risk of molar pregnancy at age > 45 compared to age 30?

Scenario 10.      What is the risk of molar pregnancy in a pregnancy after a complete mole?

Option list.

A	< 1%
B	1-2%
C	3-5%
D	6-10%
E	11-20%
F	> 20%

Scenario 11.      What is the risk of molar pregnancy in a pregnancy after a partial mole?

Use the option list from the previous question.

Scenario 12.      Which, if any, of the following are more common in pregnancy after a molar

pregnancy? This is not a true EMQ as there may be > 1 correct answer.

Option list.

A	anaemia
B	eclampsia / severe PET
C	intrauterine growth retardation
D	miscarriage
E	premature labour
F	PPH
G	pulmonary embolism
G	none of the above

Scenario 13.      Which, if any, of the following statements about hCG are true?

A	is a glycoprotein
B	shares its α sub-unit with FSH, LH & TSH
C	shares its α sub-unit with FSH & LH but not TSH
D	shares its β sub-unit with FSH, LH & TSH
E	shares its β sub-unit with FSH & LH but not TSH
F	β-core exists as a sub-type of β-hCG
G	nicked free-β exists as a sub-type of β-hCG
H	c-terminal peptide exists as a sub-type of β-hCG
I	hCG β core fragment may lead to false –ve results with urine pregnancy tests
J	heterophile antibodies may give false +ve hCG results
K	heterophile antibodies are not found in urine

Scenario 14.      Which, if any, of the following statements are true in relation to the diagnosis of molar

pregnancy ?

A	definite diagnosis is usually made by ultrasound
B	definitive diagnosis requires a +ve test for P57KIP2
C	definitive diagnosis requires an hCG level > twice the median value for gestation
D	definite diagnosis requires histological examination
E	none of the above

Scenario 15.      Cystic placental spaces in the placenta and a ratio of transverse to anterioposterior

measurements of the gestation sac <1.5 are strongly suggestive of a partial mole. True / False.

Scenario 16.      When should invasive karyotype testing be considered?

A	twin pregnancy with complete mole and a normal twin
B	uncertainty whether this is a complete mole with a normal twin or possible partial mole
C	partial molar pregnancy
D	suspected mesenchymal hyperplasia of the placenta
E	recurrent molar pregnancy
F	none of the above

Scenario 17.      Which, if any, of the following statements are true about twin pregnancy with a viable

pregnancy and a CHM?

A	the woman should be referred to a feto-maternal specialist
B	the woman should be referred to a GTDTC
C	fetal karyotyping should be done
D	the rate of early fetal loss is about 20%
E	the rate of preterm birth is about 40%
F	the rate of preeclampsia is 20%
G	the incidence of GTN in doubled if the pregnancy goes beyond 24 weeks

Scenario 18.      Which, if any, of the following statements are true about preparation of the cervix

before evacuation of molar pregnancy?

A	medical preparation is of proven efficacy in making suction evacuation easier
B	medical preparation with prostaglandins ↑ trophoblastic embolisation
C	medical preparation with prostaglandins ↑ the risk of needing chemotherapy
D	GTG 38 recommends the use of laminaria tents
E	none of the above

Scenario 19.      Which, if any, of the following statements are true about evacuation of molar

pregnancies?

A	medical management is recommended for both CMs and PMs to ↓ the risk of bleeding
B	medical management is recommended for both CMs and PMs to ↓ the risk of dissemination of trophoblastic tissue
C	medical management is recommended for both CMs and PMs to ↓ the risk of uterine perforation
D	suction evacuation is recommended for both CMs and PMs
E	suction evacuation is recommended for CMs
F	suction evacuation is recommended for PMs so long as fetal parts are not too big
G	mifepristone + misoprostol treatment is an acceptable alternative to suction evacuation.
H	oxytocin administration after suction evacuation is recommended to ↓ bleeding
I	none of the above

Scenario 20.      What is the management of suspected molar ectopic pregnancy?

A	usual management for ectopic pregnancy
B	usual management + any tissue obtained sent to GTDTC
C	methotrexate followed by usual surgical management
D	referral to GTDTC
E	none of the above.

Scenario 21.      What is the management of placental site trophoblastic tumour?

A	referral to GTDTC
B	referral to GTDTC, methotrexate and any tissue sent to GTDTC
C	referral to GTDTC, hysterectomy and tissue sent to GTDTC
D	referral to and management by GTDTC
E	none of the above.

Scenario 22.      What is the management of epitheliod trophoblastic tumour?

Use the option list from Scenario 21.

Scenario 23.      What is the management of placental site nodule?

Use the option list from Scenario 21.

Scenario 24.      What is the management of atypical placental site nodule?

Use the option list from Scenario 21.

Scenario 25.      Which, if any, of the following statements are true about urinary hCG testing in

relation to avoiding failure to diagnose molar pregnancy?

A	testing should be done 3 weeks after medical evacuation of complete moles
B	testing should be done 3 weeks after surgical evacuation of complete moles
C	testing should be done 3 weeks after medical evacuation of partial moles
D	testing should be done 3 weeks after surgical evacuation of complete moles
E	testing should be done 3 weeks after medical evacuation of ‘failed’ pregnancy
F	testing should be done 3 weeks after surgical evacuation of ‘failed’ pregnancy
G	testing should be done 3 weeks after medical evacuation of ‘failed’ pregnancy, but only if POC have not been sent for histological examination
H	testing should be done 3 weeks after surgical evacuation of ‘failed’ pregnancy, but only if POC have not been sent for histological examination
I	testing should be done 3 weeks after medical evacuation of incomplete miscarriage
J	testing should be done 3 weeks after surgical evacuation of incomplete miscarriage
K	testing should be done 3 weeks after medical evacuation of incomplete miscarriage, but only if POC have not been sent for histological examination
L	testing should be done 3 weeks after surgical evacuation of incomplete miscarriage, but only if POC have not been sent for histological examination
M	none of the above

Scenario 26.      Which, if any, of the following statements are true in relation to histological

examination of POC after TOP?

A	it should be done in all cases to exclude GTD
B	it should be done in all cases that have not had pre-op ultrasound examination in case the pregnancy was an unsuspected ectopic. Absence of trophoblastic tissue on histology will raise suspicion of the diagnosis
C	it should be done in all cases where ultrasound has not shown a viable pregnancy
D	it should be done in all cases where ultrasound has not shown fetal parts.
E	none of the above

Scenario 27.      Which, if any, of the following statements are true in relation to RhD and GTD?

A	CHMs have no RhD
B	PHMs have no RhD
C	Anti-D should be withheld until histological results are available
D	‘C’ is true, but only in relation to CMs
E	‘C’ is true, but only in relation to PMs
F	none of the above

Scenario 28.      Which, if any, of the following statements are true in relation to GTN?

A	always arises from molar pregnancy
B	may occur after normal pregnancy and livebirth
C	may arise as primary ovarian neoplasia
D	the incidence after complete molar pregnancy is greater than after partial molar pregnancy
E	the incidence after livebirth is estimated at 1 in 50,000

Scenario 29.      Which, if any, of the following statements are true in relation to p57^KIP2?

A	it is a tumour suppressor gene, found in complete and partial moles but not choriocarcinoma
B	takes us to the world of genomic imprinting
C	is an example of uniparental disomy
D	is a gene found in chromosomes of maternal origin, but not paternal
E	is a gene found in chromosomes of paternal origin, but not maternal
F	can help to distinguish complete and partial moles
G	none of the above

Scenario 30.      What is the risk of persistent GTD after a complete mole?

Scenario 31.      What is the risk of requiring chemotherapy after a complete mole?

Scenario 32.      What is the risk of persistent GTD after a partial mole?

Scenario 33.      What is the risk of requiring chemotherapy after a partial mole?

Scenario 34.      What is the risk of requiring chemotherapy with hCG level > 20,000 i.u. 4⁺¹ weeks after

 evacuation?

Scenario 35.      What is the overall risk of requiring chemotherapy after molar pregnancy in the UK?

Scenario 36.      What is the risk of requiring chemotherapy in the USA compared with the UK?

Scenario 37.      Which, if any, of the following are grounds for offering chemotherapy after

hydatidiform mole?

A	hCG > 10,000 IU/L > 4 weeks after evacuation
B	hCG > 20,000 IU/L > 4 weeks after evacuation
C	↑ hCG in two consecutive serum samples
D	hCG the same in two consecutive samples
E	raised, but falling,  hCG level 3 months after evacuation
F	persistent bleeding 3 months after evacuation

Scenario 38.      What are the risk factors included in the FIGO scoring system?

Scenario 39.      Which, if any, of the following statements is true about the recommended treatment

of low-risk GTN?

A	low risk is defined as WHO score ≤ 5
B	low risk is defined as WHO score ≤ 6
C	low risk means that no treatment is necessary
D	treatment of low risk GTN is methotrexate
E	treatment of low risk GTN is folic acid
F	treatment of low risk GTN is folinic acid

Scenario 40.      Which, if any, of the following is the most common side-effect of methotrexate?

A	alopecia
B	anaemia
C	aphasia
D	nausea
E	myelosuppression
F	none of the above.

Scenario 41.      Which, if any, of the following statements are true about the use of folic acid / folinic

 acid in methotrexate treatment regimens? There may be > 1 correct answer.

A	folic acid must be converted to tetrahydrofolate to be biologically active
B	folic acid must be converted to folinic acid to be biologically active
C	dihydrofolate reductase converts folic acid to folinic acid
D	dihydrofolate reductase converts folic acid to tetrahydrofolate
E	dihydrofolate reductase converts folinic acid to tetrahydrofolate
F	folinic acid is used in preference to folic acid as it reaches higher levels in plasma
G	folate therapy is used to reduce GI tract damage from methotrexate
H	folate therapy is used to reduce hepatic damage from methotrexate
I	folate therapy is used to reduce neurological damage from methotrexate
J	folate therapy is used to reduce renal damage from methotrexate
K	none of the above.

Scenario 42.      When is repeat surgical evacuation of the uterus appropriate?

Scenario 43.      Which, if any, of the following statements are true about the recommended duration

of follow-up after GTD? This is not a true EMQ as there may be > 1 correct answer.

A	6 months from the time the hCG falls to normal
B	6 months from the date of evacuation of the GTD if the hCG falls to normal within 56 days
C	6 months from the date of the hCG falling to normal if it does so within 56 days
D	6 months from the date of evacuation of the GTD if the hCG falls to normal after 56 days
E	6 months from the date of the hCG falling to normal if it does so after 56 days
F	56 days after the first full moon after the evacuation of the GTD

Scenario 44.      What is the approximate cure rate for GTN with a FIGO risk score ≤ 6?

A	70%
B	80%
C	90%
D	95%
E	98%
F	100%

Scenario 45.      What is the approximate cure rate for GTN with a FIGO risk score >7?

A	70%
B	80%
C	90%
D	95%
E	98%
F	100%

Scenario 46.      When should the possibility of persistent GTD be investigated after non-molar

pregnancy?

A	if there is abnormal bleeding
B	if there is persistent abnormal bleeding
C	if there is cough
D	if there is new-onset dyspnoea
E	if there is pleurodynia

Scenario 47.      A woman wishes to become pregnant after a pregnancy with GTD. Which, if any, of

the following statements are true about the advice she should be given about an appropriate inter-pregnancy interval?

A	not before follow-up is complete
B	not for at least 3/12 after completion of follow-up
C	not for at least 6/12 after completion of follow-up
D	not for at least 12/12 after completion of follow-up
E	she should be advised not to become pregnant if chemotherapy was needed
F	not for at least 6 months after completion of follow-up if chemotherapy was needed
G	none of the above

Scenario 48.      Which of the following statements are true about combined hormonal contraception

use after GTD?

A	it may increase the risk of GTN if used before hCG levels have returned to normal
B	is not associated with additional risk
C	intra-uterine contraceptives are preferable

Scenario 49.      Which, if any, of the following statements are true about the long-term issues for

women who have needed chemotherapy for GTN?

A	the menopause is likely to be earlier
B	the risk of other cancers is not increased
C	there is evidence of ↑ risk of breast cancer
D	there is evidence of ↑ risk of colon cancer
E	there is evidence of ↑ risk of myeloid leukaemia
F	there is evidence of ↑ risk of melanoma
H	there is no evidence of addition risk with HRT

Scenario 50.      A woman had a complete mole in her first pregnancy. She is pregnant for the second

 time. What is the risk of another molar pregnancy?

Scenario 51.      A woman has had two molar pregnancies. What is the risk of molar pregnancy if she

becomes pregnant again?

Scenario 52.          A woman has had three molar pregnancies. What is the risk of molar pregnancy if

she becomes pregnant again?

Scenario 53.      Which, if any, of the following statements are correct in relation to recurrence of

molar pregnancy?

A	the histological type is likely to be the same
B	the histological type in recurrent mole after a complete mole is likely to be partial mole
C	the histological type in recurrent mole after a partial mole is likely to be complete mole
D	the histological type after PSTT is likely to be choriocarcinoma
E	none of the above

Scenario 54.      A woman has a normal pregnancy after treatment for hydatidiform mole. Which, if

any, of the following statements are true about the need for hCG testing 6 weeks after the pregnancy?

A	testing is optional
B	testing is only needed for women with persisting GTD
C	testing is only needed for women with persisting GTN
D	testing is only needed for women who have needed chemotherapy
E	testing should be offered to all women who use hair dye

Scenario 55.      What proportion of women remain fertile after treatment for GTN?

A	80%
B	70%
C	60%
D	50%
E	40%

Scenario 56.      What proportion of women will reach the menopause by age 40 after chemotherapy

for GTN?

A	10%
B	20%
C	30%
D	40%
E	50%

 

FSRHCAP has a SBA. It is open access, so reproduced here. It is badly-worded, mistaking GTD for GTN, but highlights some of the key points.

With gestational trophoblastic disease (GTD), which statement is false?

A. After complete hydatidiform mole, 15–20% women develop GTD needing chemotherapy

B. After partial hydatidiform mole, 30–35% women develop GTD needing chemotherapy

C. Intrauterine contraception is unsuitable while human chorionic gonadotropin is still detectable

D. Combined hormonal contraception can be used if gestational trophoblastic neoplasia develops

Answer. GTG38 says the risk of GTN requiring chemotherapy is about 13–16% for CHM and 0.5–1.0% for PHM, so both A & B are false, but B more so than A.

 

11.         EMQ. Kallmann’s syndrome.

Abbreviations.

Ks:         Kallmann’s syndrome

Scenario 23. Which of the following might be included in descriptions of Kallmann’s syndrome?

Option list.

A	hypogonadotrophic hypogonadism
B	hypogonadotrophic hypogonadism + anosmia
C	hypogonadotrophic hypogonadism + anosmia + colour-blindness.
D	hypogonadotrophic hypogonadism due to uterine agenesis

Scenario 24. Which, if any, of the following are features of the Kallmann phenotype?

A	absent or minimal breast development
B	aortic stenosis
C	blue eyes
D	blue hair
E	hot flushes
F	short stature
G	tall stature
H	vaginal agenesis
I	none of the above

Scenario 25. How common is Kallmann’s syndrome and what is the female: male ratio?

A	1 in 1,000 and F:M ratio 1:1
B	1 in 5,000 and F:M ratio 1:1
C	1 in 10,000 and F:M ratio 1:4
D	1 in 50,000 and F:M ratio 1:4
E	1 in 100,000 and F:M ratio 1:8
F	1 in 250,000 and F:M ration 1:10

Scenario 26. What is the most common mode of inheritance of Ks?

Option list.

A	hypogonadotrophic hypogonadism
B	hypogonadotrophic hypogonadism + anosmia
C	hypogonadotrophic hypogonadism due to uterine agenesis
D	autosomal dominant
E	autosomal recessive
F	X-linked recessive
G	new mutation of the ANOS1 gene
H	the most common mode of inheritance is not known

Scenario 27. How is Kallmann’s syndrome diagnosed?

A	abdominal and pelvic ultrasound scan
B	cell-free fetal DNA
C	chromosome analysis
D	CT scan of hypothalamus / pituitary
E	MR scan of hypothalamus / pituitary
F	none of the above.

Scenario 28. How is Kallmann’s syndrome treated initially?

Which of the following statements are true?

Option list.

A	GnRH analogue depot
B	pulsatile GnRH therapy
C	combined oral contraceptive
D	counselling & education re gender re-assignment
E	depot progestogen
F	none of the above

Scenario 29. A woman was diagnosed with Kallmann’s syndrome at 16 and had successful initial

treatment. She is now 25, married and wishes to have a pregnancy. She has had pre-pregnancy assessment and counselling. Which of the following should be considered?

A	GnRH analogue depot
B	induction of ovulation with clomiphene
C	gonadotrophin therapy
D	pulsatile GnRH therapy
E	none of the above

 

12.         SBA. Fetal origins of adult disease.

Abbreviations.

ADHD:  attention-deficit, hyperactivity disorder

Lead in. These questions relate to disease in adults resulting from events during fetal, infant and child development.

Scenario 1.   What eponymous title is given to the concept that adverse intra-uterine conditions

predispose to the development of disease in adulthood?

Option List                               

A	the Barker hypothesis
B	the Baker’s dozen
C	the Broadbank theory
D	PIPAD: Placental Insufficiency Programmes Adult Disease
E	SIMCARD: Stop In-utero Malnutrition to Conquer Adult-resulting Disease

Scenario 2.   Which other term is used for the concept that adverse intra-uterine conditions

 predispose to the development of disease in adulthood?

Option List

A	FDAD: fetal determination of adult disease
B	FIAD:   fetal influences on adult disease
C	FIDAD: fetal and infancy determinants of adult disease
D	FIGO:   fetal influences on genomic outcomes
E	FP:       fetal programming

Scenario 3.   Which of the following is thought to increase the risk of adult disease?

Option List

A	low birthweight (LBW)
B	LBW followed by poor weight gain in infancy and childhood
C	LBW followed by poor weight gain in infancy but above-average weight gain in childhood
D	above-average birthweight (AABW)
E	AABW followed by poor weight gain in infancy but above-average weight gain in childhood
F	AABW followed by above-average weight gain in infancy and childhood

Scenario 4.   Which adult diseases are generally believed to be more likely in relation to adverse

influences on the fetus, infant and child.

Diseases.

A	asthma
B	chronic bronchitis
C	coronary heart disease
D	diabetes type I
E	diabetes type 2
F	hypertension
G	Mendelson’s syndrome
H	Stroke

Scenario 5.   What adult condition has been linked to raised maternal c-reactive protein levels?

Option List                               

A	asthma
B	ADHD
C	autism
D	inflammatory bowel disease
E	schizophrenia