|
18 |
Viva. Topic announced on the day |
|
19 |
EMQ. Hepatitis D |
|
20 |
EMQ. Relugolix |
|
21 |
EMQ. Cytomegalovirus and pregnancy.
CMV. |
|
22 |
EMQ. Galactosaemia |
|
23 |
EMQ. Uterine inversion |
18. Viva. Topic announced on the day.
19. EMQ. Hepatitis D.
Question
1.
What is the most
common cause of acute viral hepatitis in the UK?
Option list.
|
A |
hepatitis A virus |
|
B |
hepatitis B virus |
|
C |
hepatitis C virus |
|
D |
hepatitis D virus |
|
E |
hepatitis E virus |
|
F |
herpes simplex virus |
|
G |
HIV |
Question
2.
Which, if any, of
the following are correct about HEV.
Option list.
|
A |
it is a DNA virus |
|
B |
it belongs to the genus Hippieviridae |
|
C |
it belongs to the genus Hepeviridae |
|
D |
it belongs to the genus Hoppieviridae |
|
E |
there are six main genotypes |
|
F |
genotype 3 is the one of greatest importance in the UK |
|
G |
the main reservoir of genotype 3 is intensively-reared
chickens |
|
H |
the main reservoir of genotype 3 is domestic cats |
|
I |
a vaccine exists but is only licensed in Russia |
|
J |
none of the above |
Question
3.
Which, if any, of
the following statements about HEV and pregnancy are true?
Option list.
|
A |
pregnant women are more susceptible to HEV infection |
|
B |
pregnant women are more likely to develop serious
disease that the non-pregnant |
|
C |
the main risk is neonatal death due to vertical transmission |
|
D |
the main risk is maternal death |
|
E |
the risk of maternal death is highest with infection in
the 1st. trimester |
|
F |
↑ rates of preterm birth have been
reported |
|
G |
↑ rates
of stillbirth have been reported |
20. EMQ. Relugolix.
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 |
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 |
21. EMQ. Cytomegalovirus and pregnancy. CMV.
Abbreviations.
AI: avidity
index.
CMV: cytomegalovirus.
CNS: central
nervous system.
FGR: fetal
growth restriction.
HIG: hyperimmunoglobulin.
IUFD: intrauterine fetal death.
Scenario 1.
What does the term
“cytomegalovirus” mean?
Option list.
|
A |
it is an unusually large virus |
|
B |
it is the largest known virus |
|
C |
the viral cytoplasm is increased in volume |
|
D |
infected cells are enlarged and have enlarged nuclei |
|
E |
none of the above |
Scenario 2.
Which of the
following terms is used in relation to CMV infected cells?
Option list.
|
A |
almond-eyed |
|
B |
apple of my eye |
|
C |
cross-eyed |
|
D |
doe-eyed |
|
E |
owl-eyed |
Scenario 3.
Which family of
viruses does CMV belong to?
Option list.
|
A |
Adenoviridae |
|
B |
Arachnoviridae |
|
C |
Enteroviridae |
|
D |
Herpesviridae |
|
E |
Poxviridae |
Scenario 4.
What kind of virus
is CMV?
Option list.
|
A |
bacteriophage |
|
B |
DNA virus |
|
C |
RNA virus |
|
D |
none of the above |
Scenario 5.
What is the
structure of the herpes virus?
Option list.
|
A |
double-stranded DNA core, surrounded by three layers:
capsid, tegument and envelope |
|
B |
single-stranded DNA core, surrounded by two layers:
capsid and envelope |
|
C |
double-stranded RNA core, surrounded by three layers:
capsid, tegument and envelope |
|
D |
single-stranded RNA core, surrounded by two layers:
capsid and envelope |
|
E |
none of the above |
Scenario 6.
How many herpes
viruses have been described?
Option list.
|
A |
>1,000 |
|
B |
> 500 |
|
C |
> 250 |
|
D |
> 100 |
|
E |
none of the above. |
Scenario 7.
How many herpes
viruses are of relevance to human infection?
Option list.
|
A |
8 |
|
B |
10 |
|
C |
12 |
|
D |
14 |
|
E |
20 |
Scenario 8.
Write the list of
herpes viruses which affect humans and the conditions they cause?
Option list. There is
none. You have to write your own list.
Scenario 9.
Where does CMV
rank in the list of the most common causes of congenital viral
infection?
Option list.
|
A |
1 |
|
B |
2 |
|
C |
3 |
|
D |
4 |
|
E |
5 |
Scenario 10.
Which of the
following statements is the most accurate in relation to CMV?
Option list.
|
A |
CMV can lie dormant after 1ry. infection, usually in
bone marrow |
|
B |
CMV can lie dormant after 1ry. infection, usually in
dorsal root ganglia |
|
C |
CMV can lie dormant after 1ry. infection, usually in
the lungs |
|
D |
CMV can lie dormant after 1ry. infection, usually in
the salivary glands |
|
E |
CMV does not lie dormant after 1ry. infection |
Scenario 11.
Which, if any, of
the following statements is true of CMV & pregnancy in the UK?
Option list.
|
A |
approximately 10-20% of women are immune before their 1st.
pregnancy |
|
B |
approximately 20-30% of women are immune before their 1st.
pregnancy |
|
C |
approximately 30-50% of women are immune before their 1st.
pregnancy |
|
D |
approximately 40-60% of women are immune before their 1st.
pregnancy |
|
E |
none of the above |
Scenario 12.
Which of the
following statements is true in relation to vertical transmission?
Option list.
|
A |
it is mainly transplacental |
|
B |
it is mainly due to feto-maternal haemorrhage |
|
C |
it mainly occurs during labour and delivery |
|
D |
it mainly occurs during lactation |
|
E |
none of the above |
Scenario 13.
What is the approximate
incidence of 1ry. CMV infection in pregnancy?
Option list.
|
A |
< 1% |
|
B |
< 5% |
|
C |
< 7.5% |
|
D |
< 10% |
|
E |
≥ 10% |
Scenario 14.
What is the
biggest source of CMV infection for women of reproductive age?
Option list.
|
A |
contaminated food or water |
|
B |
blood transfusion |
|
C |
infected sexual partner |
|
D |
infected small children |
|
E |
undercooked meat, particularly pork |
Scenario 15.
What proportion of
1ry. maternal CMV infection in pregnancy is asymptomatic?
Option list.
|
A |
up to 10% |
|
B |
11 – 29% |
|
C |
30 – 49% |
|
D |
50 – 79% |
|
E |
80 – 89% |
|
F |
≥ 90% |
Scenario 16.
What is the
approximate prevalence of CMV infection in UK neonates?
Option list.
|
A |
0.10- 0.25% |
|
B |
0.10- 0.50% |
|
C |
0.20- 0.50% |
|
D |
0.20- 1.00% |
|
E |
0.20- 2.25% |
Scenario 17.
Where does CMV
rank in the non-genetic causes of SNHL in children?
Option list.
|
A |
1 |
|
B |
2 |
|
C |
3 |
|
D |
4 |
|
E |
none of the above |
Scenario 18.
When does vertical
transmission carry the greatest risk of inflicting neurological
damage on the fetus?
Option list.
|
A |
with 1ry infection during the 1st. trimester |
|
B |
with 2ry infection during the 1st. trimester |
|
C |
with 1ry infection during the 2nd. trimester |
|
D |
with 2ry infection during the 2nd. trimester |
|
E |
with 1ry infection during the 3rd. trimester |
|
F |
with 2ry infection during the 3rd. trimester |
|
G |
with 1ry infection during labour / delivery |
|
H |
with 2ry infection during labour / delivery |
|
I |
none of the above |
Scenario 19.
What is the risk
of vertical transmission after CMV infection in the immediate
preconception period?
Option list.
|
A |
< 1% |
|
B |
1-5% |
|
C |
6-10% |
|
D |
11-15% |
|
E |
16-20% |
|
F |
21-30% |
Scenario 20.
A fetus is
infected with CMV at the time of highest risk for neurological damage. What
is the approximate upper limit
for the risk that the child will have neurological damage?
Option list.
|
A |
up to 1% |
|
B |
up to 5% |
|
C |
up to 7.5% |
|
D |
up to 10% |
|
E |
up to 12.5% |
|
F |
up to 15% |
|
G |
up to 20% |
|
H |
none of the above |
Scenario
21. Approximately what % of cerebral palsy is thought
attributable to fetal CMV?
Option list.
|
A |
1% |
|
B |
5% |
|
C |
7.5% |
|
D |
10% |
|
E |
12.5% |
|
F |
15% |
|
G |
20% |
|
H |
25% |
Scenario 22.
Approximately what
% of SNHL is thought attributable to fetal CMV infection?
Option list.
|
A |
1% |
|
B |
5% |
|
C |
7.5% |
|
D |
10% |
|
E |
12.5% |
|
F |
15% |
|
G |
20% |
|
H |
25% |
Scenario 23.
Which, if any, of
the following statements is true of CMV?
Option list.
|
A |
1ry. infection is followed by life-long latent
infection |
|
B |
1ry. infection is followed by life-long latent
infection in a minority of cases |
|
C |
life-long latent infection is characteristic of CMV but
not other herpes viruses |
|
D |
life-long latent infection only occurs after 2ry.
infection |
|
E |
none of the above. |
Scenario 24.
How is 1ry.
maternal CMV infection best diagnosed?
Option list.
|
A |
by the regional laboratory |
|
B |
IgM to IgG conversion |
|
C |
presence of IgM with low avidity IgG |
|
D |
religious conversion |
|
E |
sero-conversion from IgG -ve to IgG +ve |
Scenario 25.
Which, if any, of
the following is true in relation to ‘avidity’ in CMV infection?
Option list.
|
A |
avidity declines directly with the interval from 1ry
infection to the test |
|
B |
avidity is an indirect measure of viral load |
|
C |
avidity measures the determination of the obstetrician
to make a diagnosis |
|
D |
avidity measures the enthusiasm of the laboratory for
maximising the cost of testing |
|
E |
avidity measures the strength of binding of CMV
antibody to the virus |
Scenario 26.
Which, if any, of
the following is true in relation to the CMV ‘avidity index’?
Option list.
|
A |
the AI is the ratio of free: albumin-bound CMV IgG in
maternal serum |
|
B |
the AI is the IgG antibody titre in maternal serum |
|
C |
the AI is the percentage of IgG that is bound to the
antigen |
|
D |
the AI is the amount of IgG bound to the antigen
expressed as micrograms / gram |
|
E |
none of the above |
Scenario 27.
Which, if any, of
the following is true in relation to the CMV ‘avidity index’?
Option list.
|
A |
an AI < 30 is indicative of old infection |
|
B |
an AI < 30 is indicative of recent 1ry infection |
|
C |
an AI < 30 suggests a faulty assay |
|
D |
the AI assay used in the NHS is standard across all
laboratories |
|
E |
none of the above |
Scenario 28.
Which, if any, of the following
statements is true in relation to identifying women at greatest risk of having
a baby with severe congenital infection?
Option list.
|
A |
a low AI < 18 weeks indicates high risk |
|
B |
a high AI < 18 weeks indicates high risk |
|
C |
a high IgM titre indicates low risk |
|
D |
a high IgG titre indicates high risk |
|
E |
none of the above |
Scenario 29.
What is UK policy
in relation to routine screening for CMV in pregnancy?
Option list.
|
A |
routine screening was introduced in 2018 |
|
B |
routine screening is not advocated because of cost |
|
C |
routine screening is not advocated because of the lack
of an accurate test |
|
D |
routine screening is not advocated because of cross-reaction
with EBV |
|
E |
none of the above |
Scenario 30.
What is UK policy
in relation to routine screening of the neonate for CMV?
Option list.
|
A |
routine screening was introduced in 2015 |
|
B |
routine screening is not advocated because of cost |
|
C |
routine screening is not advocated because of the lack
of an accurate test |
|
D |
routine screening is not advocated because of cross-reaction
with EBV |
|
E |
none of the above |
Scenario
31. Pick the true statements from the list below.
Option list.
|
A |
avidity testing
is not done on CMV IgM antibodies |
|
B |
CMV IgG is a
maverick and does not play by the usual rules |
|
C |
CMV IgM is a
maverick and does not play by the usual rules |
|
D |
CMV IgG
persists for many years |
|
E |
CMV IgM
persists for 1 year or more |
|
F |
none of the
above |
Scenario 32.
A woman has been
shown to have had CMV infection in pregnancy. It is decided to
check for evidence of fetal
infection. What does SIP56 say is the mainstay of diagnosing fetal CMV
infection.?
Option list.
|
A |
amniocentesis and PCR for evidence of CMV |
|
B |
amniocentesis and electron microscopy for evidence of
CMV |
|
C |
amniocentesis and light microscopy for evidence of CMV |
|
D |
amniocentesis and viral culture |
|
E |
MRI |
|
F |
ultrasound – abdominal |
|
G |
ultrasound - transvaginal |
Scenario 33.
A woman has been
shown to have had CMV infection in pregnancy. Which, if any of
the following statements best
describe the role of MRI scanning in assessing the fetus? This is not a true
EMQ as more than one statement may be true.
Option list.
|
A |
it should be offered in conjunction with ultrasound |
|
B |
it should be offered if ultrasound examination suggests
fetal infection |
|
C |
it should be offered if ultrasound examination does not
suggest fetal infection |
|
D |
it should be offered if there is sufficient funding to
pay for it |
|
E |
the role of MRI scanning is not yet clear |
|
F |
none of the above |
Scenario 34.
A pregnant woman
is HIV+ve? Which of the following statements is true?
Option list.
|
A |
the risk of vertical transmission in pregnancy is ↑ |
|
B |
the risk of vertical transmission in pregnancy is ↓ |
|
C |
the risk of vertical transmission in pregnancy is the
same as in HIV-ve women |
Scenario 35.
A pregnant woman
is HIV+ve? Which of the following statements is true?
Option list.
|
A |
her neonate is at ↑
risk of acquiring CMV perinatally |
|
B |
her neonate is at ↓
risk of acquiring CMV perinatally |
|
C |
her neonate is at normal risk of acquiring CMV
perinatally |
|
D |
none of the above |
Scenario 36.
A pregnant woman
is HIV+ve? Her neonate is +ve for both CMV and HIV. Which of the
following statements is true?
Option list.
|
A |
the child has a ↓
risk of HIV progression and ↓
risk of CNS damage from CMV |
|
B |
the child has a ↓
risk of HIV progression and ↑
risk of CNS damage from CMV |
|
C |
the child has a ↓
risk of HIV progression and normal risk of CNS damage from CMV |
|
D |
the child has an ↑
risk of HIV progression and ↓
risk CNS damage from CMV |
|
E |
the child has an ↑
risk of HIV progression and ↑
risk CNS damage from CMV |
|
F |
the child has an ↑
risk of HIV progression and normal risk of CNS damage from CMV |
|
G |
the child has a normal risk of HIV progression and ↓ risk of CNS damage from CMV |
|
H |
the child has a normal risk of HIV progression ↑ risk of CNS damage from CMV |
|
I |
the child has a normal risk of both HIV progression and
CNS damage from CMV |
Scenario 37.
Which of the
following treatments in pregnancy is of proven efficacy and safety in
reducing the risk of vertical
transmission to the fetus?
Option list.
|
A |
acyclovir |
|
B |
CMV vaccine |
|
C |
ganciclovir |
|
D |
HIG |
|
E |
valaciclovir |
|
F |
none of the above |
TOG CPD
Comprehensive review and update of
cytomegalovirus infection in pregnancy
Regarding cytomegalovirus (CMV),
1. it is a double-stranded RNA herpes
virus. True False
2. it is the commonest congenital viral
infection in
the developed world. True False
3. prevalence is most common in social
class V. True False
Regarding CMV morbidity,
4. it is the leading genetic cause of
sensorineural deafness. True False
5. maternal infection occurring in the
third
trimester carries the highest risk to
the
fetus. True False
6. previous infection confers complete
future
immunity to the mother. True False
Regarding feto-maternal transmission of
CMV,
7. there is good evidence to suggest
that
gestational age has no apparent influence
on
risk of transmission. True False
8. breastfeeding is a route of
transmission. True False
9. for healthy mature babies, an
infection with
the CMV through breastmilk does not pose
significant danger. True False
10. transmission can be reduced by
appropriate
hand washing after nappy changes and
exposure to bodily fluids, avoiding
kissing
young children on mouth and cheeks and
by
avoiding sharing food, drinks or
utensils with
young children. True False
11. primary infection, reactivation and
reinfection
with different CMV strains during pregnancy
has been shown to lead to congenital
CMV. True False
Regarding maternal CMV in pregnancy,
12. diagnosis of maternal CMV based on
symptoms is reliable with over 70% of
women
presenting with classic symptoms. True False
13. viral reactivation is more common in
HIV
positive pregnant women. True False
Regarding diagnosis of CMV infection in
pregnancy,
14. seroconversion of CMV specific
immunoglobulin G (IgG) in paired acute
and
convalescent sera is diagnostic of a new
acute infection. True False
15. When prepregnancy status is unknown,
detection of immunoglobulin M (IgM)-
specific antibody is diagnostic of
primary infection. True False
16. IgM serology is imprecise for
determining
primary infection as it has been shown
to
remain positive for up to a year
following
acute infection. True False
17. The presence of IgG and IgM CMV
antibodies
with low CMV antibody avidity is
diagnostic
of primary infection. True False
Concerning congenital CMV infection,
18. 85% are asymptomatic at birth. True False
19. 30% of affected infants will develop
neurological sequelae. True False
20. 15% of infants born to mothers with
recurrent
CMV infection are overtly symptomatic. True False
Comprehensive review and update
of cytomegalovirus infection in pregnancy.
These derive from the TOG
article by Navti et al. The article is from 2016 and is open-access.
TOG. Volume
18, Issue 4 October 2016 Pages 301–7.
Some of the questions are badly
written – I would expect exam questions to be better.
Regarding cytomegalovirus
(CMV),
1. it is a double-stranded RNA herpes virus. True False
2. it is the commonest congenital viral
infection in the developed world. True False.
3. prevalence is most common in social class
V. True False
Regarding CMV morbidity,
4. it is the leading genetic cause of
sensorineural deafness. True False
5. maternal infection occurring in the 3rd.
trimester carries the highest risk to the fetus. True False
6. previous infection confers complete future
immunity to the mother. True False
Regarding feto-maternal transmission of CMV,
7. there is good evidence to suggest that
gestational age has no apparent influence on risk of transmission. True False
8. breastfeeding is a route of transmission. True False
9. for healthy mature babies, an infection
with the CMV through breastmilk does not pose significant danger. True False
10. transmission can be reduced by appropriate
hand washing after nappy changes and exposure to bodily fluids, avoiding
kissing young children on mouth and cheeks and by avoiding sharing food, drinks
or utensils with young children. True False
11. primary infection, reactivation and
reinfection with different CMV strains during pregnancy has been shown to lead
to congenital CMV. True False
Regarding maternal CMV in pregnancy,
12. diagnosis of maternal CMV based on symptoms
is reliable with over 70% of women presenting with classic symptoms. True False
13. viral reactivation is more common in HIV
positive pregnant women. True False
Regarding diagnosis of CMV infection in pregnancy,
14. seroconversion of CMV specific immunoglobulin
G (IgG) in paired acute and convalescent sera is diagnostic of a new acute
infection. True False
15. When prepregnancy status is unknown, detection
of immunoglobulin M (IgM)- specific antibody is diagnostic of primary
infection. True False
16. IgM serology is imprecise for determining
primary infection as it has been shown to remain positive for up to a year
following acute infection. True
17. The presence of IgG and IgM CMV antibodies
with low CMV antibody avidity is diagnostic of primary infection. True False
Concerning congenital CMV infection,
18. 85% are asymptomatic at birth. True False
19. 30% of affected infants will develop
neurological sequelae. True False
20. 15% of infants born to mothers with recurrent
CMV infection are overtly symptomatic.
True False
22. EMQ. Galactosaemia.
Cytomegalovirus infection in pregnancy.
Abbreviations.
AI: avidity
index.
CMV: cytomegalovirus.
CNS: central
nervous system.
FGR: fetal
growth restriction.
HIG: hyperimmunoglobulin.
IUFD: intrauterine fetal death.
Scenario 1.
What does the term
“cytomegalovirus” mean?
Option list.
|
A |
it is an unusually large virus |
|
B |
it is the largest known virus |
|
C |
the viral cytoplasm is increased in volume |
|
D |
infected cells are enlarged and have enlarged nuclei |
|
E |
none of the above |
Scenario 2.
Which of the
following terms is used in relation to CMV infected cells?
Option list.
|
A |
almond-eyed |
|
B |
apple of my eye |
|
C |
cross-eyed |
|
D |
doe-eyed |
|
E |
owl-eyed |
Scenario 3.
Which family of
viruses does CMV belong to?
Option list.
|
A |
Adenoviridae |
|
B |
Arachnoviridae |
|
C |
Enteroviridae |
|
D |
Herpesviridae |
|
E |
Poxviridae |
Scenario 4.
What kind of virus
is CMV?
Option list.
|
A |
bacteriophage |
|
B |
DNA virus |
|
C |
RNA virus |
|
D |
none of the above |
Scenario 5.
What is the
structure of the herpes virus?
Option list.
|
A |
double-stranded DNA core, surrounded by three layers:
capsid, tegument and envelope |
|
B |
single-stranded DNA core, surrounded by two layers:
capsid and envelope |
|
C |
double-stranded RNA core, surrounded by three layers:
capsid, tegument and envelope |
|
D |
single-stranded RNA core, surrounded by two layers:
capsid and envelope |
|
E |
none of the above |
Scenario 6.
How many herpes
viruses have been described?
Option list.
|
A |
>1,000 |
|
B |
> 500 |
|
C |
> 250 |
|
D |
> 100 |
|
E |
none of the above. |
Scenario 7.
How many herpes
viruses are of relevance to human infection?
Option list.
|
A |
8 |
|
B |
10 |
|
C |
12 |
|
D |
14 |
|
E |
20 |
Scenario 8.
Write the list of
herpes viruses which affect humans and the conditions they cause?
Option list. There is
none. You have to write your own list.
Scenario 9.
Where does CMV
rank in the list of the most common causes of congenital viral
infection?
Option list.
|
A |
1 |
|
B |
2 |
|
C |
3 |
|
D |
4 |
|
E |
5 |
Scenario 10.
Which of the
following statements is the most accurate in relation to CMV?
Option list.
|
A |
CMV can lie dormant after 1ry. infection, usually in
bone marrow |
|
B |
CMV can lie dormant after 1ry. infection, usually in
dorsal root ganglia |
|
C |
CMV can lie dormant after 1ry. infection, usually in
the lungs |
|
D |
CMV can lie dormant after 1ry. infection, usually in
the salivary glands |
|
E |
CMV does not lie dormant after 1ry. infection |
Scenario 11.
Which, if any, of
the following statements is true of CMV & pregnancy in the UK?
Option list.
|
A |
approximately 10-20% of women are immune before their 1st.
pregnancy |
|
B |
approximately 20-30% of women are immune before their 1st.
pregnancy |
|
C |
approximately 30-50% of women are immune before their 1st.
pregnancy |
|
D |
approximately 40-60% of women are immune before their 1st.
pregnancy |
|
E |
none of the above |
Scenario 12.
Which of the
following statements is true in relation to vertical transmission?
Option list.
|
A |
it is mainly transplacental |
|
B |
it is mainly due to feto-maternal haemorrhage |
|
C |
it mainly occurs during labour and delivery |
|
D |
it mainly occurs during lactation |
|
E |
none of the above |
Scenario 13.
What is the approximate
incidence of 1ry. CMV infection in pregnancy?
Option list.
|
A |
< 1% |
|
B |
< 5% |
|
C |
< 7.5% |
|
D |
< 10% |
|
E |
≥ 10% |
Scenario 14.
What is the
biggest source of CMV infection for women of reproductive age?
Option list.
|
A |
contaminated food or water |
|
B |
blood transfusion |
|
C |
infected sexual partner |
|
D |
infected small children |
|
E |
undercooked meat, particularly pork |
Scenario 15.
What proportion of
1ry. maternal CMV infection in pregnancy is asymptomatic?
Option list.
|
A |
up to 10% |
|
B |
11 – 29% |
|
C |
30 – 49% |
|
D |
50 – 79% |
|
E |
80 – 89% |
|
F |
≥ 90% |
Scenario 16.
What is the
approximate prevalence of CMV infection in UK neonates?
Option list.
|
A |
0.10- 0.25% |
|
B |
0.10- 0.50% |
|
C |
0.20- 0.50% |
|
D |
0.20- 1.00% |
|
E |
0.20- 2.25% |
Scenario 17.
Where does CMV
rank in the non-genetic causes of SNHL in children?
Option list.
|
A |
1 |
|
B |
2 |
|
C |
3 |
|
D |
4 |
|
E |
none of the above |
Scenario 18.
When does vertical
transmission carry the greatest risk of inflicting neurological
damage on the fetus?
Option list.
|
A |
with 1ry infection during the 1st. trimester |
|
B |
with 2ry infection during the 1st. trimester |
|
C |
with 1ry infection during the 2nd. trimester |
|
D |
with 2ry infection during the 2nd. trimester |
|
E |
with 1ry infection during the 3rd. trimester |
|
F |
with 2ry infection during the 3rd. trimester |
|
G |
with 1ry infection during labour / delivery |
|
H |
with 2ry infection during labour / delivery |
|
I |
none of the above |
Scenario 19.
What is the risk
of vertical transmission after CMV infection in the immediate
preconception period?
Option list.
|
A |
< 1% |
|
B |
1-5% |
|
C |
6-10% |
|
D |
11-15% |
|
E |
16-20% |
|
F |
21-30% |
Scenario 20.
A fetus is
infected with CMV at the time of highest risk for neurological damage. What
is the approximate upper limit
for the risk that the child will have neurological damage?
Option list.
|
A |
up to 1% |
|
B |
up to 5% |
|
C |
up to 7.5% |
|
D |
up to 10% |
|
E |
up to 12.5% |
|
F |
up to 15% |
|
G |
up to 20% |
|
H |
none of the above |
Scenario 21.
Approximately what
% of cerebral palsy is thought attributable to fetal CMV?
Option list.
|
A |
1% |
|
B |
5% |
|
C |
7.5% |
|
D |
10% |
|
E |
12.5% |
|
F |
15% |
|
G |
20% |
|
H |
25% |
Scenario 22.
Approximately what
% of SNHL is thought attributable to fetal CMV infection?
Option list.
|
A |
1% |
|
B |
5% |
|
C |
7.5% |
|
D |
10% |
|
E |
12.5% |
|
F |
15% |
|
G |
20% |
|
H |
25% |
Scenario 23.
Which, if any, of
the following statements is true of CMV?
Option list.
|
A |
1ry. infection is followed by life-long latent
infection |
|
B |
1ry. infection is followed by life-long latent
infection in a minority of cases |
|
C |
life-long latent infection is characteristic of CMV but
not other herpes viruses |
|
D |
life-long latent infection only occurs after 2ry.
infection |
|
E |
none of the above. |
Scenario 24.
How is 1ry.
maternal CMV infection best diagnosed?
Option list.
|
A |
by the regional laboratory |
|
B |
IgM to IgG conversion |
|
C |
presence of IgM with low avidity IgG |
|
D |
religious conversion |
|
E |
sero-conversion from IgG -ve to IgG +ve |
Scenario 25.
Which, if any, of
the following is true in relation to ‘avidity’ in CMV infection?
Option list.
|
A |
avidity declines directly with the interval from 1ry
infection to the test |
|
B |
avidity is an indirect measure of viral load |
|
C |
avidity measures the determination of the obstetrician
to make a diagnosis |
|
D |
avidity measures the enthusiasm of the laboratory for
maximising the cost of testing |
|
E |
avidity measures the strength of binding of CMV
antibody to the virus |
Scenario 26.
Which, if any, of
the following is true in relation to the CMV ‘avidity index’?
Option list.
|
A |
the AI is the ratio of free: albumin-bound CMV IgG in
maternal serum |
|
B |
the AI is the IgG antibody titre in maternal serum |
|
C |
the AI is the percentage of IgG that is bound to the
antigen |
|
D |
the AI is the amount of IgG bound to the antigen
expressed as micrograms / gram |
|
E |
none of the above |
Scenario 27.
Which, if any, of
the following is true in relation to the CMV ‘avidity index’?
Option list.
|
A |
an AI < 30 is indicative of old infection |
|
B |
an AI < 30 is indicative of recent 1ry infection |
|
C |
an AI < 30 suggests a faulty assay |
|
D |
the AI assay used in the NHS is standard across all
laboratories |
|
E |
none of the above |
Scenario 28.
Which, if any, of the following
statements is true in relation to identifying women at greatest risk of having
a baby with severe congenital infection?
Option list.
|
A |
a low AI < 18 weeks indicates high risk |
|
B |
a high AI < 18 weeks indicates high risk |
|
C |
a high IgM titre indicates low risk |
|
D |
a high IgG titre indicates high risk |
|
E |
none of the above |
Scenario 29.
What is UK policy
in relation to routine screening for CMV in pregnancy?
Option list.
|
A |
routine screening was introduced in 2018 |
|
B |
routine screening is not advocated because of cost |
|
C |
routine screening is not advocated because of the lack
of an accurate test |
|
D |
routine screening is not advocated because of cross-reaction
with EBV |
|
E |
none of the above |
Scenario 30.
What is UK policy
in relation to routine screening of the neonate for CMV?
Option list.
|
A |
routine screening was introduced in 2015 |
|
B |
routine screening is not advocated because of cost |
|
C |
routine screening is not advocated because of the lack
of an accurate test |
|
D |
routine screening is not advocated because of cross-reaction
with EBV |
|
E |
none of the above |
Scenario 31.
Pick the true
statements from the list below.
Option list.
|
A |
avidity testing is not done on CMV IgM antibodies |
|
B |
CMV IgG is a maverick and does not play by the usual
rules |
|
C |
CMV IgM is a maverick and does not play by the usual
rules |
|
D |
CMV IgG persists for many years |
|
E |
CMV IgM persists for 1 year or more |
|
F |
none of the above |
Scenario 32.
A woman has been
shown to have had CMV infection in pregnancy. It is decided to
check for evidence of fetal
infection. What does SIP56 say is the mainstay of diagnosing fetal CMV
infection.?
Option list.
|
A |
amniocentesis and PCR for evidence of CMV |
|
B |
amniocentesis and electron microscopy for evidence of
CMV |
|
C |
amniocentesis and light microscopy for evidence of CMV |
|
D |
amniocentesis and viral culture |
|
E |
MRI |
|
F |
ultrasound – abdominal |
|
G |
ultrasound - transvaginal |
Scenario 33.
A woman has been
shown to have had CMV infection in pregnancy. Which, if any of
the following statements best
describe the role of MRI scanning in assessing the fetus? This is not a true
EMQ as more than one statement may be true.
Option list.
|
A |
it should be offered in conjunction with ultrasound |
|
B |
it should be offered if ultrasound examination suggests
fetal infection |
|
C |
it should be offered if ultrasound examination does not
suggest fetal infection |
|
D |
it should be offered if there is sufficient funding to
pay for it |
|
E |
the role of MRI scanning is not yet clear |
|
F |
none of the above |
Scenario 34.
A pregnant woman
is HIV+ve? Which of the following statements is true?
Option list.
|
A |
the risk of vertical transmission in pregnancy is ↑ |
|
B |
the risk of vertical transmission in pregnancy is ↓ |
|
C |
the risk of vertical transmission in pregnancy is the
same as in HIV-ve women |
Scenario 35.
A pregnant woman
is HIV+ve? Which of the following statements is true?
Option list.
|
A |
her neonate is at ↑
risk of acquiring CMV perinatally |
|
B |
her neonate is at ↓
risk of acquiring CMV perinatally |
|
C |
her neonate is at normal risk of acquiring CMV
perinatally |
|
D |
none of the above |
Scenario 36.
A pregnant woman
is HIV+ve? Her neonate is +ve for both CMV and HIV. Which of the
following statements is true?
Option list.
|
A |
the child has a ↓
risk of HIV progression and ↓
risk of CNS damage from CMV |
|
B |
the child has a ↓
risk of HIV progression and ↑
risk of CNS damage from CMV |
|
C |
the child has a ↓
risk of HIV progression and normal risk of CNS damage from CMV |
|
D |
the child has an ↑
risk of HIV progression and ↓
risk CNS damage from CMV |
|
E |
the child has an ↑
risk of HIV progression and ↑
risk CNS damage from CMV |
|
F |
the child has an ↑
risk of HIV progression and normal risk of CNS damage from CMV |
|
G |
the child has a normal risk of HIV progression and ↓ risk of CNS damage from CMV |
|
H |
the child has a normal risk of HIV progression ↑ risk of CNS damage from CMV |
|
I |
the child has a normal risk of both HIV progression and
CNS damage from CMV |
Scenario 37.
Which of the
following treatments in pregnancy is of proven efficacy and safety in
reducing the risk of vertical
transmission to the fetus?
Option list.
|
A |
acyclovir |
|
B |
CMV vaccine |
|
C |
ganciclovir |
|
D |
HIG |
|
E |
valaciclovir |
|
F |
none of the above |
TOG CPD
Comprehensive review and update of
cytomegalovirus infection in pregnancy
Regarding cytomegalovirus (CMV),
1. it is a double-stranded RNA herpes
virus. True False
2. it is the commonest congenital viral
infection in
the developed world. True False
3. prevalence is most common in social
class V. True False
Regarding CMV morbidity,
4. it is the leading genetic cause of
sensorineural deafness. True False
5. maternal infection occurring in the
third
trimester carries the highest risk to
the
fetus. True False
6. previous infection confers complete
future
immunity to the mother. True False
Regarding feto-maternal transmission of
CMV,
7. there is good evidence to suggest
that
gestational age has no apparent influence
on
risk of transmission. True False
8. breastfeeding is a route of
transmission. True False
9. for healthy mature babies, an
infection with
the CMV through breastmilk does not pose
significant danger. True False
10. transmission can be reduced by
appropriate
hand washing after nappy changes and
exposure to bodily fluids, avoiding
kissing
young children on mouth and cheeks and
by
avoiding sharing food, drinks or
utensils with
young children. True False
11. primary infection, reactivation and
reinfection
with different CMV strains during pregnancy
has been shown to lead to congenital
CMV. True False
Regarding maternal CMV in pregnancy,
12. diagnosis of maternal CMV based on
symptoms is reliable with over 70% of
women
presenting with classic symptoms. True False
13. viral reactivation is more common in
HIV
positive pregnant women. True False
Regarding diagnosis of CMV infection in
pregnancy,
14. seroconversion of CMV specific
immunoglobulin G (IgG) in paired acute
and
convalescent sera is diagnostic of a new
acute infection. True False
15. When prepregnancy status is unknown,
detection of immunoglobulin M (IgM)-
specific antibody is diagnostic of
primary infection. True False
16. IgM serology is imprecise for
determining
primary infection as it has been shown
to
remain positive for up to a year
following
acute infection. True False
17. The presence of IgG and IgM CMV
antibodies
with low CMV antibody avidity is
diagnostic
of primary infection. True False
Concerning congenital CMV infection,
18. 85% are asymptomatic at birth. True False
19. 30% of affected infants will develop
neurological sequelae. True False
20. 15% of infants born to mothers with
recurrent
CMV infection are overtly symptomatic. True False
Comprehensive review and update
of cytomegalovirus infection in pregnancy.
These derive from the TOG
article by Navti et al. The article is from 2016 and is open-access.
TOG. Volume
18, Issue 4 October 2016 Pages 301–7.
Some of the questions are badly
written – I would expect exam questions to be better.
Regarding cytomegalovirus
(CMV),
1. it is a double-stranded RNA herpes virus. True False
2. it is the commonest congenital viral
infection in the developed world. True False.
3. prevalence is most common in social class
V. True False
Regarding CMV morbidity,
4. it is the leading genetic cause of
sensorineural deafness. True False
5. maternal infection occurring in the 3rd.
trimester carries the highest risk to the fetus. True False
6. previous infection confers complete future
immunity to the mother. True False
Regarding feto-maternal transmission of CMV,
7. there is good evidence to suggest that
gestational age has no apparent influence on risk of transmission. True False
8. breastfeeding is a route of transmission. True False
9. for healthy mature babies, an infection
with the CMV through breastmilk does not pose significant danger. True False
10. transmission can be reduced by appropriate
hand washing after nappy changes and exposure to bodily fluids, avoiding
kissing young children on mouth and cheeks and by avoiding sharing food, drinks
or utensils with young children. True False
11. primary infection, reactivation and
reinfection with different CMV strains during pregnancy has been shown to lead
to congenital CMV. True False
Regarding maternal CMV in pregnancy,
12. diagnosis of maternal CMV based on symptoms
is reliable with over 70% of women presenting with classic symptoms. True False
13. viral reactivation is more common in HIV
positive pregnant women. True False
Regarding diagnosis of CMV infection in pregnancy,
14. seroconversion of CMV specific immunoglobulin
G (IgG) in paired acute and convalescent sera is diagnostic of a new acute
infection. True False
15. When prepregnancy status is unknown, detection
of immunoglobulin M (IgM)- specific antibody is diagnostic of primary
infection. True False
16. IgM serology is imprecise for determining
primary infection as it has been shown to remain positive for up to a year
following acute infection. True
17. The presence of IgG and IgM CMV antibodies
with low CMV antibody avidity is diagnostic of primary infection. True False
Concerning congenital CMV infection,
18. 85% are asymptomatic at birth. True False
19. 30% of affected infants will develop
neurological sequelae. True False
20. 15% of infants born to mothers with recurrent
CMV are overtly symptomatic. True False
23. EMQ. Uterine inversion.
Abbreviations.
MROP: manual removal of placenta.
UI: uterine inversion.
Question
1.
How is uterine
inversion categorised and how are the categories defined?
This is not an EMQ and there is
no option list.
Question
2.
What is the approximate
incidence of UI?
Option list.
|
A |
1 in 1,000 |
|
B |
1 in 2,000 |
|
C |
1 in 4,000 |
|
D |
1 in 6,000 |
|
E |
1 in 10,000 |
|
F |
1 in 20,000 |
|
G |
1 in 100,00 |
Question
3.
What is the approximate
incidence of UI?
Option list.
|
A |
1 in 1,000 |
|
B |
1 in 2,000 |
|
C |
1 in 4,000 |
|
D |
1 in 6,000 |
|
E |
1 in 10,000 |
|
F |
1 in 20,000 |
|
G |
1 in 100,00 |
Question
4.
Is the incidence
of UI higher in less-well developed countries?
Option list.
|
A |
answer unknown |
|
B |
no |
|
C |
yes |
Question
5.
What is the approximate
incidence of UI during Caesarean section?
Option list.
|
A |
1 in 1,000 |
|
B |
1 in 2,000 |
|
C |
1 in 4,000 |
|
D |
1 in 6,000 |
|
E |
1 in 10,000 |
|
F |
1 in 20,000 |
|
G |
1 in 100,00 |
Question
6.
Which, if any, of the
following are described as risk factors for UI?
Option list.
|
A |
abruptio placenta |
|
B |
Caesarean section |
|
C |
Credé’s manoeuvre |
|
D |
fundal placenta |
|
E |
hydramnios |
|
F |
lax uterus |
|
G |
Marfan syndrome |
|
H |
mismanagement of the 2nd. stage of labour |
|
I |
mismanagement of the 3rd. stage of labour |
|
J |
oxytocic use |
|
K |
postpartum haemorrhage |
|
L |
short cord |
Question
7.
What are the
presenting features of UI? There is no option list.
Question
8.
What is the
immediate management of UI? There is no option list.
Question
9.
What procedure
should be considered if the inversion is not corrected during initial
management? There is no option list.
Question
10. What is Huntington’s procedure?.
Question
11. What is Haultain’s procedure ? There is no option list.
Question
12. What other procedures have been described? There is no
option list.
Question
13. What should be done to ensure the inversion does not recur?
There is no option list.
Question
14. What is the risk of recurrence in the next pregnancy? There
is no option list.
Acute inversion of the uterus
With regard to acute uterine
inversion,
1 it is
spontaneous in up to 50% of cases. True / False
2 its incidence
is similar in most parts of the world. True / False
The associated risk factors for acute inversion of the
uterus include:
3 injudicious traction
on the umbilical cord. True / False
4 manual removal
of the placenta. True / False
5 uterine atony. True / False
6 fundal
implantation of a morbidly adherent placenta. True / False
7 placenta
praevia. True / False
Recognised features of acute inversion of the uterus
include:
8 haemorrhage. True / False
9 neurogenic
shock. True / False
10 severe abdominal
pain. True / False
11 postpartum
collapse. True / False
12 lump per vaginam.
True / False
Regarding management of acute uterine inversion,
13 the best
treatment is immediate repositioning of the uterus. True / False
14 the use of tocolysis
to promote uterine relaxation will aid uterine reposition. True / False
15 magnesium sulphate
is not used for tocolysis. True / False
16 in the presence
of shock, terbutaline is acceptable as a safe agent for uterine relaxation.
True / False
17 when halothane
is used to encourage uterine relaxation severe hypotension is a recognised complication.
True / False
With regard to future pregnancy,
18 the condition
carries a good prognosis if managed correctly. True / False
Regarding treatment of acute inversion,
19 in fewer than
3% of cases, women will need to undergo laparotomy. True / False
20 immediate reduction
is successful in approximately 50–80% of cases. True / False
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