MRCOGManchester: MRCOG tutorial Thursday 5th. December 2024

2 December 2024.

Specialist talks which can be downloaded from Dropbox.

Specialist talk. Julie Morris. Medical statistics	7	Oct
Specialist talk. Jenny Myers. Diabetes & pregnancy	10	Oct
Specialist talk. Jenny Myers. Hypertension & pregnancy	14	Oct
Specialist talk. Martino Zacchè. Uro-gynae	21	Oct
TMcF. Maternal & Perinatal mortality. MBRRACE. UKOSS	24	Oct
Specialist talk. Janette Mill. Progression and assessment of training.	28	Oct
Specialist talk. Janette Mill. Abnormal bleeding on HRT.	28	Oct

Programme 5 December 2024.

29	EMQ. Gestational trophoblastic disease
30	SBA. Lynch syndrome
31	MCQ5.6&46. Ergot and ergometrine
32	MCQ7.23. Folic acid fortification of flour
33	EMQ. Folic acid fortification of flour
34	EMQ. The MAGPIE trial
35	EMQ. Clue cells, koilocytes

29. Gestational Trophoblastic Disease (GTD).

Abbreviations.

CHM: complete hydatidiform mole.

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
CC	false
DD	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.

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?

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?

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.

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 P57^KIP2
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 typical 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.

TOG has some questions from Savage and 2008. Volume 10. 1.

Molar pregnancy With regard to molar pregnancy,

1. it arises from a genetic error occurring at or before the time of fertilisation. T F

2. the risk is highest in teenage mothers. T F

3. the risk of malignant change, if partial, is 10 times less than if complete. T F

4. the longer the interval between diagnosis of molar pregnancy and initiation of chemotherapy, the poorer the prognosis. T F

5. repeated uterine evacuation is recommended where serum human chorionic gonadotrophin (hCG) levels are 5000 iu/l. T F

6. methotrexate/folinic acid chemotherapy is effective treatment in the majority of cases of persistent trophoblast disease following molar pregnancy. T F

7. 24-hour advice on treatment of women overseas is available in specialist treatment centres in the UK. T F

In women with complete molar pregnancy,

8. there are 69 chromosomes present in the conception. T F

9. the diagnostic clinical features are bleeding, excessive morning sickness, abdominal pain and a large-for-dates uterus. T F

10. there is a 10–20% chance that they will require further treatment with chemotherapy. T F

With regard to the treatment of women with persistent trophoblast disease,

11. the initial investigations carried out should include measurement of hCG levels to exclude a new pregnancy. T F

12. initial pretreatment levels of hCG help identify the need for a longer inpatient stay. T F

13. approximately 30% of women in the low-risk group will require second-line chemotherapy. T F

14. treatment with single-agent methotrexate increases the lifetime risk of myeloid leukaemia. T F

15. treatment of women in the high-risk group with etoposide/methotrexate/dactinomycin, followed by cyclophosphamide/vincristine, results in a cure rate of 90%. T F Which of the following statements about chemotherapy for molar pregnancy are correct?

16. Approximately 5% of women with persistent trophoblast disease following molar pregnancy fall in the high-risk category for chemotherapy. T F

17. When women with high-risk persistent trophoblast disease are treated with the combination of EMA/CO, approximately a third of them will develop resistance. T F

18. Following successful chemotherapy, the risk of relapse is approximately 3–5%. T F

19. In those developing relapse, the cure rate varies between approximately 85–100%, depending on whether they are high or low risk. T F

20. Chemotherapy for molar pregnancy is associated with a 2.5-fold increase in the lifetime risk of developing a second malignancy. T F

30. Lynch syndrome.

Abbreviations

CRC: colorectal cancer.

EC: endometrial cancer.

IBD: inflammatory bowel disease: Crohn’s & ulcerative colitis.

IDDM: insulin-dependent diabetes mellitus.

Ls: Lynch syndrome.

MLH: mutL-homolog family of DNA, mismatch repair genes.

MMR: mismatch repair.

MSH: mutS homolog family of DNA, mismatch repair genes.

Question 1. What is Lynch syndrome?

Option List

A	auto-immune condition leading to reduced factor X levels in blood
B	hereditary condition which increases the risk of many cancers, particularly breast
C	hereditary condition which increases the risk of many cancers, particularly breast & colorectal
D	hereditary condition which increases the risk of many cancers, particularly colorectal & endometrial
E	none of the above

Question 2. How is Lynch syndrome inherited?

Option List

A	it is an autosomal dominant condition
B	it is an autosomal recessive condition
C	it is an X-linked dominant condition
D	it is an X-linked recessive condition
E	none of the above

Question 3. Which, if any, of the following genes can cause Lynch syndrome?

Option List

A	MLH1 + MLH2 + MOH1
B	MLH1 + MLH2 + MSH1
C	MLH1 + MLH2 + MSH6
D	MLH1 + MSH2 + MSH6 + PMS2
E	None of the above

Question 4. Mutations of which 2 of the following genes cause most cases of Lynch syndrome?

Option List

A	MLH1 + MLH2
B	MLH1 + MSH1
C	MLH1 + MSH2
D	MLH2 + MSH1
E	MLH2 + MSH2

Question 5. What is the approximate prevalence of Ls in the UK population?

Option List

A	1 in 50
B	1 in 100
C	1 in 1,000
D	3 in 1,000
E	none of the above

Question 6. Approximately what % of individuals with Ls have had the diagnosis established?

Option List

A	< 5%
B	5 -10%
C	10-20%
D	20-30%
E	>30%

Question 7. Which, if any, of the following conditions are associated with an ↑ risk of Ls?

Option List

A	acromegaly + Addison’s disease + coeliac disease + IBD + IDDM
B	acromegaly + disease + anosmia + coeliac disease + IBD
C	acromegaly + IBD + IDDM
D	acromegaly + IBD
E	Addison’s disease + anosmia + coeliac disease + IBD + IDDM
F	acromegaly + Addison’s disease + anosmia + coeliac disease + IBD + IDDM
G	none of the above

Question 8. Which 2 cancers are most likely in women with Lynch syndrome?

Option List

A	breast + bowel
B	breast + pancreas
C	breast + endometrium
D	bowel + cervix
E	bowel + endometrium
F	bowel + ovary
G	bowel + pancreas
H	endometrium + ovary

Question 9. What does NICE recommend about screening for Lynch syndrome for the population

with no personal history of colorectal cancer?

Option List

A	offer screening to those aged < 50 years with ≥ 1 affected 1^st.^O relative
B	offer screening to those aged < 60 years with ≥ 1 affected 1^st.^O relative
C	offer screening to those with ≥ 1 affected 1^st.^O relative aged < 50 years at diagnosis
D	offer screening to those with ≥ 1 affected 1^st.^O relative aged < 60 years at diagnosis
E	none of the above

Question 10. What does NICE recommend in relation to screening for Lynch syndrome in those with

a new diagnosis of colorectal cancer?

Option List

A	offer screening to everyone, regardless of age and family history
B	offer screening to those aged < 50 years at diagnosis
C	offer screening to those aged < 60 years at diagnosis
D	offer screening to those aged < 50 years at diagnosis with + ≥ 1 affected 1^st.^O relative
E	offer screening to those aged < 60 years at diagnosis with + ≥ 1 affected 1^st.^O relative

Question 11. What does NICE recommend about screening for Lynch syndrome for the population

with no personal history of thyroid cancer?

Option List

A	offer screening to those aged < 50 years with ≥ 1 affected 1^st.^O relative
B	offer screening to those aged < 60 years with ≥ 1 affected 1^st.^O relative
C	offer screening to those with ≥ 1 affected 1^st.^O relative aged < 50 years at diagnosis
D	offer screening to those with ≥ 1 affected 1^st.^O relative aged < 60 years at diagnosis
E	none of the above

Question 12. What does NICE recommend in relation to screening for Lynch syndrome in those

with a new diagnosis of thyroid cancer?

Option List

A	offer screening to everyone, regardless of age and family history
B	offer screening to those aged < 50 years at diagnosis
C	offer screening to those aged < 60 years at diagnosis
D	offer screening to those aged < 50 years at diagnosis with + ≥ 1 affected 1^st.^O relative
E	none of the above

Question 13. What does NICE recommend about screening for Lynch syndrome for the population

with no personal history of endometrial cancer?

Option List

A	offer screening to those aged < 50 years with ≥ 1 affected 1^st.^O relative
B	offer screening to those aged < 60 years with ≥ 1 affected 1^st.^O relative
C	offer screening to those with ≥ 1 affected 1^st.^O relative aged < 50 years at diagnosis
D	offer screening to those with ≥ 1 affected 1^st.^O relative aged < 60 years at diagnosis
E	none of the above

Question 14. What does NICE recommend in relation to screening for Lynch syndrome in those with

a new diagnosis of endometrial cancer?

Option List

A	offer screening to those aged < 50 years with ≥ 1 affected 1^st.^O relative
B	offer screening to those aged < 60 years with ≥ 1 affected 1^st.^O relative
C	offer screening to those with ≥ 1 affected 1^st.^O relative aged < 50 years at diagnosis
D	offer screening to those with ≥ 1 affected 1^st.^O relative aged < 60 years at diagnosis
E	none of the above

Question 15. What does NICE recommend about screening for Lynch syndrome for the population

with no personal history of colorectal cancer?

Option List

A	offer screening to those aged < 50 years with ≥ 1 affected 1^st.^O relative
B	offer screening to those aged < 60 years with ≥ 1 affected 1^st.^O relative
C	offer screening to those with ≥ 1 affected 1^st.^O relative aged < 50 years at diagnosis
D	offer screening to those with ≥ 1 affected 1^st.^O relative aged < 60 years at diagnosis
E	none of the above

Question 16. What does NICE recommend in relation to screening for Lynch syndrome in those with

a new diagnosis of colorectal cancer?

Option List

A	offer screening to everyone, regardless of age and family history
B	offer screening to those aged < 50 years at diagnosis
C	offer screening to those aged < 60 years at diagnosis
D	offer screening to those aged < 50 years at diagnosis with + ≥ 1 affected 1^st.^O relative
E	offer screening to those aged < 60 years at diagnosis with + ≥ 1 affected 1^st.^O relative

Question 17. What relationship, if any, exists between Ls and acromegaly?

Option List

A	the risk of Ls is ↓ in those with acromegaly compared with the general population
B	the risk of Ls is ↑ in those with acromegaly compared with the general population
C	the risk of Ls is unchanged in those with acromegaly compared with the general population
D	the risk of Ls in unknown in those with acromegaly
E

Question 18. What is the effect of aspirin consumption on the risk of EC and CRC?

Option List

A	aspirin reduces the risk of EC and CRC
B	aspirin reduces the risk of EC but not CRC
C	aspirin reduces the risk of CRC but not EC
D	aspirin does not reduce the risk of EC or CRC
E	aspirin reduces the risk of EC and CRC, but the risks outweigh the benefits

Question 19. A healthy woman of 35 years is diagnosed with Ls? What are the key elements of the

National Screening Programme for people with Ls?

There is no option list – just write down everything you know.

Question 20. Which, if any, of the following were recommendations made by Monahan et al, the 30

experts who wrote to the BMJ in 2017.

Option List

A	creation of a national register of people with Ls
B	creation of a post of Consultant in Ls for each NHS Trust
C	creation of a post of Clinical Champion for Ls in each NHS Region.
D	creation of a post of Clinical Champion for Ls in the DOH.
E	none of the above

Question 21. What research programme was established in 2024 in the hope of reducing cancer incidence in those with L?

A	LynchAspirin
B	LynchEndo
C	LynchGene
D	LynchMicrobiome
E	LynchVax
F	none of the above

Question 22. When was the UK Lynch syndrome national registry established?

A	2000
B	2006
C	2012
D	2028
E	2022
F	2024

CPD questions for TOG. 2021.Volume 23, Issue 1 has the CPD questions linked to the Ryan article, but they are not yet open access, so you will need to download them. I have prepared answers – try to answer them before the tutorial.

31. Ergot and Ergometrine. MCQ paper 5 – available on Dropbox.

Q6. Ergometrine.

a. is given in a dosage of 5 mg. in the active management of the third stage of labour.

b. is contra-indicated in cases of significant hypertension.

c. may cause significant fluid retention.

d. may cause nausea and vomiting.

e. is contra-indicated in patients with epilepsy.

f. causes strong rhythmic uterine contractions.

Q46. Ergot & its alkaloids:

a. ergot is due to infection with Claviceps purpurea.

b. ergot poisoning was associated with rye bread.

c. Lonitzer wrote in 1582 of the use of ergot to expedite childbirth.

d. ergotism may cause hallucinations.

e. LSD is an ergot alkaloid.

f. bromocriptine is an ergot alkaloid.

32. MCQ7.23. Folic acid fortification of flour.

Abbreviations.

FFF: fortification of flour with folic acid.

NTD: neural tube defect.

23. Folic acid & pregnancy.

a. the dosage for routine prophylaxis of neural tube defect is 0.4 mg. daily.

b. the dosage for prophylaxis for patients with spina bifida or who have had a pregnancy affected by neural tube defect is 5mg. daily.

c. folic acid reduces the risk of neural tube defect by more than 70%.

d. folic acid and anti-epilepsy drugs may interact adversely.

e. folic acid reduces the risk of placental abruption.

f. folic acid can provoke sub-acute combined degeneration of the cord.

g. fortification of flour with folic acid was introduced in the USA in 1998.

h. fortification of flour with folic acid in the USA has been linked to a 50% reduction in the incidence of neural tube defects.

i. fortification of flour with folic acid was introduced in the UK in 2005.

33. Folic acid fortification of flour.

Scenario 1. What is the incidence of NTD in the UK?

Scenario 2. What is the risk of an affected sibling for the woman who becomes pregnant after

having a baby with NTD?

Scenario 3. Which foods contain significant amounts of folic acid?

Scenario 4. What percentage of folic acid is destroyed by cooking / food storage?

Scenario 5. How many people in the UK are estimated to have a folate-deficient diet?

Scenario 6. What is the significance of the MTHFR (Methylenetetrahydrofolate reductase gene)?

Scenario 7. What is the significance of the Meckel-Gruber syndrome to this issue?

Scenario 8. By what gestation has the neural tube closed?

Scenario 9. What proportion of pregnant women have taken folic acid preconceptually?

Scenario 10. What dose and duration of folic acid is advised for routine periconceptual use?

Scenario 11. List the women to whom a higher dose should be offered.

Scenario 12. How effective is periconceptual folic acid consumption in reducing NTD risk in the low-risk population?

Scenario 13. How effective is periconceptual folic acid consumption in reducing NTD risk in women who have had an affected baby?

Scenario 14. What is the risk of NTD recurrence for a woman who has had two affected babies?

Scenario 15. What is the risk of NTD in Ireland?

Scenario 16. What is the significance of the name “Bukowski” in relation to folic acid?

Scenario 17. What effect does periconceptual folic acid have on the risk of stillbirth?

Scenario 18. What effect does periconceptual folic acid have on the risk of autistic spectrum disorder?

Scenario 19. What effect does periconceptual folic acid have on maternal haemoglobin levels?

Scenario 20. What recommendations have been made by the RCOG to improve folic acid levels in pregnancy?

Scenario 21. Which names are of importance in the history of folic acid and NTD?

Scenario 22. Which neurological condition has been thought potentially problematic with folic acid supplementation?

34. MAGPIE Trial.

Question 1. Which of the following is true of the Magpie trial?

A	it compared MgSO₄ with placebo in the management of eclampsia / severe PET
B	it compared MgSO₄ with lytic cocktail in the management of eclampsia / severe PET
C	it compared MgSO₄ with phenytoin in the management of eclampsia / severe PET
D	it compared MgSO₄ with alcohol in the management of threatened premature labour
E	it compared MgSO₄ with atosiban in the management of threatened premature labour
F	it compared MgSO₄ with ritodrine in the management of threatened premature labour
G	it compared MgSO₄ with dexamethasone in the prevention of cerebral palsy due to extreme prematurity
H	it compared MgSO₄ with placebo in the prevention of cerebral palsy due to extreme prematurity
I	none of the above

Question 2. Which if any of the following are true of the Magpie trial?

A	it involved ~ 1,000 women
B	it involved ~ 10,000 women
C	it involved ~ 20,000 women
C	it involved > 20,000 women
D	it involved ~ 30 hospitals
E	it involved ~ 50 hospitals
F	it involved ~ 80 hospitals
G	it involved > 150 hospitals
H	it involved 5 countries
I	it involved 10 countries
J	it involved 20 countries
K	it involved 30 countries
L	it involved 50 countries
M	it involved >50 countries

Question 3. Which if any of the following are true?

A	almost 50% of the women were in Africa
B	almost 50% of the women were in America
C	almost 50% of the women were in Asia
D	almost 50% of the women were in Australia / New Zealand
E	almost 50% of the women were in Europe

Question 4. Which, if any, of the following is true of the Magpie trial?

A	cerebral palsy rates at 2 years were ↓ by the use of MgSO₄ in babies born < 34 weeks
B	cerebral palsy rates at 2 years were unchanged by the use of MgSO₄ in babies born < 34 week
C	eclampsia rates were reduced by about half by the use of MgSO₄
D	eclampsia rates were reduced by about half by the use of MgSO₄ but only in underdeveloped countries
E	maternal mortality was significantly ↓ by the use of MgSO₄
F	maternal mortality was significantly ↓ by the use of MgSO₄, but only in underdeveloped countries
G	premature delivery was significantly ↓ by the use of MgSO₄
H	perinatal mortality from prematurity was significantly ↓ by the use of MgSO₄

35. Clue cells, koilocytes.

Abbreviations.

Ct: Chlamydia trachomatis

HSV: Herpes simplex virus

LGV: lymphogranuloma venereum

Ng: Neisseria gonorrhoeae

Tv: Trichomonas vaginalis

Option list.

A	Actinomyces
B	Bacterial vaginosis
C	Bacteroides
D	Chlamydia trachomatis
E	Chlamydial infection of the genital tract
F	Herpes Simplex
G	Human Papilloma Virus
H	Lymphogranuloma venereum
I	Monilia
J	Neisseria gonorrhoeae
K	Trichomonas vaginalis

Scenario 1. Which option or options best fit with “clue cells”

Scenario 2. Which option or options best fit with “fishy odour”?

Scenario 3. Which option or options best fit with “flagellate organisms”?

Scenario 4. Which option or options best fit with “inflammatory smear”?

Scenario 5. Which option or options best fit with “koilocytes”?

Scenario 6. Which option or options best fit with “non-specific urethritis (NSU) in the male”?

Scenario 7. Which option or options best fit with “strawberry cervix”?

Scenario 8. Which option or options best fit with “thin grey/ white discharge”?

Scenario 9. Which option or options best fit with “white, curdy discharge”?

Scenario 10. Which option or options best fit with “frothy yellow discharge”?

Scenario 11. Which option or options best fit with “protozoan”?

Scenario 12. Which option or options best fit with “obligate intracellular organism”?

Scenario 13. Which option or options best fit with “blindness”?

Scenario 14. Which option or options best fit with “LGV”?

Scenario 15. Which option or options best fit with “multinucleated cells”?

Scenario 16. Which option or options best fit with “serotypes D–K”?

Scenario 17. Which option or options best fit with “serovars L1-L3”?

Scenario 18. Which of the following are true in relation to Amsel’s criteria?

A	used for the diagnosis of bacterial vaginosis
B	used for the diagnosis of trichomonal infection
C	clue cells present on microscopy of wet preparation of vaginal fluid
D	flagellate organism present on microscopic examination of vaginal fluid
E	pH ≤ 4.5
F	pH > 4.5
G	thin, grey-white, homogeneous discharge present
H	frothy, yellow-green discharge present
I	fishy smell on adding alkali (10%KOH)
J	fishy smell on adding acid (10%HCl)
K	koilocytes present
L	absence of vulvo-vaginal irritation

Scenario 19. Which of the following are true in relation to Nugent’s criteria?

A	used for the diagnosis of bacterial vaginosis
B	used for the diagnosis of trichomonal infection
C	clue cells present on microscopy of wet preparation of vaginal fluid
D	pH ≤ 4.5
E	pH > 4.5
F	count of lactobacilli
G	count of Gardnerella and Bacteroides
H	count of white cells

Scenario 20. Gardnerella vaginalis can be cultured from the vagina of what % of normal women?

A	< 10%
B	11 - 20%
C	21 - 30%
D	31 - 40%
E	41 - 50%
F	> 50%

MRCOGManchester

Wednesday, 4 December 2024

MRCOG tutorial Thursday 5th. December 2024

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