17 November 2016.
7
|
RCOG
sample SBAs on gynaecology,
|
8
|
EMQ. Maternal Mortality definitions
|
9
|
EMQ. Cervical cancer staging
|
10
|
EMQ. Anti-Müllerian hormone
|
11
|
Communication
skills.
|
7 SBA.
RCOG sample SBAs on gynaecology.
These can be downloaded from the RCOG website. https://www.rcog.org.uk/globalassets/documents/careers-and-training/mrcog-exam/part-2/sample-sba-questions---gynaecology.pdf.
8 EMQ.
Maternal Mortality definitions.
Lead-in.
The following scenarios relate to maternal mortality.
Pick the option that best answers the task in each
scenario from the option list.
Each option can be used once, more than once or not at
all.
Option List.
A. Death
of a woman during pregnancy and up to 6 weeks later, including accidental and
incidental causes.
B. Death
of a woman during pregnancy and up to 6 weeks later, excluding accidental and
incidental causes.
C. Death
of a woman during pregnancy and up to 52 weeks later, including accidental and
incidental causes.
D. Death
of a woman during pregnancy and up to 52 weeks later, excluding accidental and
incidental causes.
E. A
pregnancy going to 24 weeks or beyond.
F. A
pregnancy going to 24 weeks or beyond + any pregnancy resulting in a
live-birth.
G. Maternal
deaths per 100,000 maternities.
H. Maternal
deaths per 100,000 live births.
I. Direct
+ indirect deaths per 100,000 maternities.
J. Direct
+ indirect deaths per 100,000 live births.
K. Direct
death.
L. Indirect
death.
M. Early
death.
N. Late
death.
O. Extra-late
death.
P. Fortuitous
death.
Q. Coincidental
death.
R. Accidental
death.
S. Maternal
murder.
T. Not
a maternal death.
U. Yes
V. No.
W. I have no
idea.
X. None
of the above.
Abbreviations.
MMR: Maternal Mortality Rate.
MMRat: Maternal Mortality Ratio.
SUDEP: Sudden Unexplained Death in Epilepsy.
Scenario 1.
What is a Maternal Death?
Scenario 2.
A woman dies from a ruptured
ectopic pregnancy at 10 weeks’ gestation. What kind of death is it?
Scenario 3.
A woman dies from a ruptured
appendix at 10 weeks’ gestation. What kind of death is it?
Scenario 4.
A woman dies from suicide at 10 weeks’ gestation. What
kind of death is it?
Scenario 5.
A woman with a 10-year-history of coronary artery disease
dies of a coronary thrombosis at 36 weeks’ gestation. What kind of death is it?
Scenario 6.
A woman has gestational
trophoblastic disease, develops choriocarcinomas and dies from it 24 months after
the GTD was diagnosed and the uterus evacuated. What kind of death is
it?
Scenario 7
A woman develops puerperal
psychosis from which she makes a poor recovery. She kills herself when the baby
is 18 months old. What kind of death is it?
Scenario 8
A woman develops puerperal
psychosis from which she makes a poor recovery. She kills herself when the baby
is 6 months old. What kind of death is it?
Scenario 9
What is a “maternity”.
Scenario 10
What is the definition of the Maternal Mortality Rate?
Scenario 11
What is the Maternal Mortality
Ratio?
Scenario 12
A woman is diagnosed with
breast cancer. She has missed a period and a pregnancy test is +ve. She decides
to continue with the pregnancy. The breast cancer does not respond to treatment
and she dies from secondary disease at 38 weeks. What kind of death is it?
Scenario 13
A woman who has been the
subject of domestic violence is killed at 12 weeks’ gestation by her partner.
What kind of death is it?
Scenario 14
A woman is struck by lightning
as she runs across a road. As a result she falls under the wheels of a large
lorry which runs over abdomen, rupturing her spleen and provoking placental
abruption. She dies of haemorrhage, mostly from the abruption. What kind of
death is it?
Scenario 15
A woman is abducted by Martians
who are keen to study human pregnancy. She dies as a result of the treatment
she receives. As this death could only have occurred because she was pregnant,
is it a direct death?
Scenario 16
Could a maternal death from
malignancy be classified as “Direct”.
Scenario 17
Could a maternal death from
malignancy be classified as “Indirect”.
Scenario 18
Could a maternal death from
malignancy be classified as “Coincidental”?
Scenario 19.
A pregnant woman is walking on
the beach at 10 weeks when she is struck by lightning and dies. What kind of
death is this?
Scenario 20.
A woman is sitting on the beach
breastfeeding her 2-month old baby when she is struck by lightning and dies.
What kind of death is this?
9 EMQ.
Cervical cancer staging.
Lead-in.
The following scenarios relate to cervical cancer
staging.
For each, select the most appropriate staging.
Pick one option from the option list.
Each option can be used once, more than once or not at
all.
Scenario 1.
A woman of 25 has a cone
biopsy. The histology report shows squamous cell carcinoma penetrating to a
depth of 2 mm and 6 mm in width. The resection margins are tumour-free. There
is no evidence of spread outside the uterus. She is nulliparous and wishes to retain
her fertility.
Scenario 2.
A woman of 25 has a cone biopsy. The histology report
shows squamous cell carcinoma penetrating to a depth of 5 mm and 6 mm in width.
The resection margins are tumour-free. There is no evidence of spread outside
the uterus. She is nulliparous and wishes to retain her fertility.
Scenario 3.
A woman of 25 has a cone
biopsy. The histology report shows squamous cell carcinoma penetrating to a
depth of 5 mm and 6 mm in width. The resection margins are not tumour-free. There
is no evidence of spread outside the uterus. She is nulliparous and wishes to retain
her fertility.
Scenario 4.
A woman of 25 has a cone
biopsy. The histology report shows squamous cell carcinoma penetrating to a
depth of 6 mm and 3 cm in width. The resection margins are tumour-free. There
is no evidence of extension outside the uterus. She is nulliparous and wishes
to retain her fertility.
Scenario 5.
A woman of 25 has a cone
biopsy. The histology report shows squamous cell carcinoma penetrating to a
depth of 6 mm and 5 cm in width. The resection margins are tumour-free. She is
nulliparous and wishes to retain her fertility.
Scenario 6.
A woman of 38 has a cone
biopsy. The histology report shows squamous cell carcinoma penetrating to a
depth of 4 mm and 6mm in width. The resection margins are tumour-free. An MR
scan shows involvement of the lymphatic nodes in the left of the pelvis.
Scenario 7.
A woman of 45 has carcinoma of
the cervix. It extends into the parametrium, but not to the pelvic side-wall.
It involves the upper 1/3 of the vagina. There is MR evidence of para-aortic
node involvement.
Scenario 8.
A woman of 55 has carcinoma of
the cervix. It extends to the pelvic side-wall. It involves the upper 1/3 of
the vagina. She has a secondary on the end of her nose.
Scenario 9.
A woman of 55 has carcinoma of
the cervix. It involves the bladder mucosa.
Scenario 10.
A woman of 35 has a proven
cancer of the cervix with extension into the right parametrium, but not to the
pelvic side-wall. Left hydroureter and left non-functioning kidney are noted on
IVP and there is no other explanation for the findings. Cystoscopy shows
bullous oedema of the bladder mucosa.
Scenario 11.
A woman of 25 has a cone
biopsy. It shows malignant melanoma. The lesion invades to a depth of 3 mm and
is 5 mm in width. The margins of the biopsy are clear. There is evidence of
lymphatic vessel involvement. There is no evidence of spread outside the
uterus.
Option list.
Micro-invasive cervical cancer.
Stage Ia1
Stage Ia2
Stage Ia3
Stage Ib1
Stage Ib2
Stage Ib3
Stage IIa
Stage IIb
Stage IIc
Stage IIIa
Stage IIIb
Stage IIIc
Stage IVa
Stage IVb
Stage IVc
Stage Va
Stage Vb
Stage Vc
None of the above.
This question illustrates the problems surrounding
staging. If you are not a cancer specialist, it is not something that you think
about very often, if ever. So you have to put it into your list of things to revise
in the days before the exam. If you haven’t started this list, do so now.
10 EMQ. Anti-Müllerian hormone
AMH.
Abbreviations.
AFC: antral follicle count
AFP: antral follicle pool
AMH: anti-Müllerian
hormone
COC: combined
oral contraceptive
COS: controlled
ovarian stimulation
GnRHA: gonadotrophin
releasing hormone analogue
PCOS: polycystic
ovary syndrome
POF: premature
ovarian failure
SHBG: sex
hormone binding globulin
Question 1.
Lead-in
Which of
the following statements best describes AMH.
Option List
A.
|
AMH is a
GnRH analogue
|
B.
|
AMH is a decapeptide
|
C.
|
AMH is an octopeptide
|
D.
|
AMH is a glycoprotein
|
E.
|
AMH is an aromatase inhibitor
|
Question 2.
Lead-in
Option List
From whom
does the word “Müllerian” originate?
A.
|
Andreas
John Müller
|
B.
|
Johannes Peter Müller
|
C.
|
Heinrich Müller
|
D.
|
Jacob Müllerian
|
E.
|
Peter Müllerian.
|
Question 3.
Lead-in
Where is
AMH produced?
Option List
A.
|
anterior
pituitary
|
B.
|
granulosa cells
|
C.
|
granulosa and Leydig cells
|
D.
|
granulosa and Sertoli cells
|
E.
|
Sertoli cells
|
Question 4.
Lead-in
What is
the story about AMH and Swyer’s syndrome in the fetus?
Option List
A.
|
AMH and
testosterone are produced in normal amounts
|
B.
|
AMH and
testosterone are produced at about half the normal levels
|
C.
|
AMH is
produced in normal amounts; testosterone is deficient
|
D.
|
AMH is
deficient; testosterone is produced in normal amounts
|
E.
|
AMH and
testosterone are both deficient
|
Question 5.
Lead-in
Which of
the following statements best apply to AMH and the female, from intra-uterine
life to adulthood?
Option List
A.
|
ovarian
granulosa cells produce AMH from 20 weeks’ gestation and production continues throughout life
|
B.
|
ovarian granulosa cells produce AMH from 36 weeks’
gestation and production continues throughout life
|
C.
|
ovarian granulosa cells produce AMH from 20 weeks’
gestation and production continues until puberty
|
D.
|
ovarian g ranulosa cells produce AMH from 20 weeks’ gestation and production
continues until the menopause
|
E.
|
ovarian granulosa cells produce AMH from 36 weeks’
gestation and production continues until the menopause
|
Question 6.
Lead-in
Where is
AMH mostly produced?
Option List
A.
|
granulosa
cells of pre-antral and small antral follicles
|
B.
|
granulosa cells of the dominant follicle
|
C.
|
granulosa cells of primordial follicles
|
D.
|
corpus luteum
|
E.
|
anterior pituitary
|
Question 7.
Lead-in
What is
the relationship between AMH and the AFP?
Option List
A.
|
AMH
levels correlate well with the AFP
|
B.
|
AMH levels fluctuate throughout the menstrual cycle and
only correlate with the AFP between days 1 and 5
|
C.
|
AMH levels fluctuate throughout the menstrual cycle and
only correlate with the AFP about 7 days before menstruation
|
D.
|
AMH is inversely proportional to the AFP
|
E.
|
AMH does not correlate well with the AFP.
|
Question 8.
Lead-in
What is
the relationship between a woman’s reproductive potential and her age?
Option List
A.
|
Reproductive
potential is directly proportional to age
|
B.
|
Reproductive potential is inversely proportional to age
|
C.
|
Reproductive potential declines with age
|
D.
|
Reproductive potential declines exponentially with age
|
E.
|
Reproductive potential declines linearly with age
|
Question 9.
Lead-in
What is
the main effect of AMH in the female fetus?
Option List
A.
|
promotion
of the development of the para-mesonephric system
|
B.
|
promotion of the development of the mesonephric system
|
C.
|
suppression of the development of the para-mesonephric
system
|
D.
|
suppression of the development of the mesonephric
system
|
E.
|
none of the above
|
Question 10.
Lead-in
What is
the main effect of AMH in the male fetus?
Option List
A.
|
promotion
of the development of the para-mesonephric system
|
B.
|
promotion of the development of the mesonephric system
|
C.
|
suppression of the development of the para-mesonephric system
|
D.
|
suppression of the development of the mesonephric
system
|
E.
|
none of the above
|
Question 11.
Lead-in
What is
the main role of AMH in the woman of reproductive years?
Option List
A.
|
acts to encourage primordial follicles to mature and
join the pool of antral follicles
|
B.
|
acts to prevent primordial follicles maturing and
joining the pool of antral follicles
|
C.
|
is the trigger for the LH surge and ovulation
|
D.
|
maintains the corpus luteum
|
E.
|
none of the above
|
Question 12.
Lead-in
What is
the main effect of AMH on FSH within the ovary?
Option List
A.
|
it acts
to increase the effect of FSH
|
B.
|
it acts synergistically with FSH
|
C.
|
it acts to decrease the effect of FSH
|
D.
|
it blocks the effect of FSH
|
E.
|
none of the above
|
Question 13.
Lead-in
When is
the best time to measure AMH in a woman whose menstrual cycles are 28 days
long?
Option List
A.
|
days 1 –
5
|
B.
|
days 6 – 10
|
C.
|
days 11 – 15
|
D.
|
about day 21
|
E.
|
none of the above
|
Question 14.
Lead-in
What is
the significance of low AMH levels?
Option List
A.
|
indicative of reduced AFP
|
B.
|
indicative of reduced AFP and ovarian reserve
|
C.
|
indicative of hyperprolactinaemia
|
D.
|
indicative of PCOS
|
E.
|
indicative of POF
|
Question 15.
Lead-in
What is
the significance of raised AMH levels?
Option List
A.
|
indicative of increased AFP and ovarian reserve
|
B.
|
indicative of reduced AFP and ovarian reserve
|
C.
|
indicative of hyperprolactinaemia
|
D.
|
indicative of PCOS
|
E.
|
indicative of POF
|
Question 16.
Lead-in
What
happens to AMH levels in pregnancy?
Option List
A.
|
levels
fall with conception due to follicular suppression and become normal with the
return of ovulation after delivery
|
B.
|
levels remain normal until about 12 weeks, then
decline, returning to normal in the early puerperium
|
C.
|
levels remain normal until about 20 weeks, then
decline, returning to normal in the early puerperium
|
D.
|
levels remain normal until about 12 weeks, then
decline, returning to normal with the return of ovulation after delivery
|
E.
|
none of the above
|
Question 17.
Lead-in
A woman
takes a COC for 3 months. What is the likely effect on her AMH levels?
Option List
A.
|
no
significant effect
|
B.
|
reversible reduction
|
C.
|
irreversible reduction
|
D.
|
reduction to undetectable levels
|
E.
|
none of the above
|
Question 18.
Lead-in
A woman
takes a COC for 18 months. What is the likely effect on her AMH levels?
Option List
A.
|
no
significant effect
|
B.
|
reversible reduction
|
C.
|
irreversible reduction
|
D.
|
reduction to undetectable levels
|
E.
|
none of the above
|
Question 19.
Lead-in
A woman
uses a GnRHA for 3 months. What is the likely effect on her AMH levels?
Option List
A.
|
no
significant effect
|
B.
|
reversible reduction
|
C.
|
irreversible reduction
|
D.
|
reduction to undetectable levels
|
E.
|
none of the above
|
Question 20.
Lead-in
A woman
uses a GnRHA for 18 months. What is the likely effect on her AMH levels?
Option List
A.
|
no
significant effect
|
B.
|
reversible reduction
|
C.
|
irreversible reduction
|
D.
|
reduction to undetectable levels
|
E.
|
none of the above
|
Question 21.
Lead-in
Which of
the following statements is correct?
Option List
A.
|
ART is
futile and should be declined in women with AMH levels < 0.1 mcg/l
|
B.
|
ART is futile and should be declined in women with AMH
levels < 0.5 mcg/l
|
C.
|
ART is futile and should be declined in women with AMH
levels < 1 mcg/l
|
D.
|
ART is futile and should be declined in women with AMH
levels < 5 mcg/l
|
E.
|
none of the above
|
Question 22.
Lead-in
Which, if
any, of the following statements is the most accurate in relation to AMH as a
marker for ovarian reserve?
Statements
A.
|
AMH is
equivalent to AFC as a marker for ovarian reserve
|
B.
|
AMH is inferior to AFC as a marker for ovarian reserve
|
C.
|
AMH is superior to AFC as a marker for ovarian reserve
|
D.
|
AMH is inferior to FSH & inhibin B assay as a
marker for primordial follicle numbers
|
E.
|
AMH is superior to FSH & inhibin B assay as a
marker for primordial follicle numbers
|
Question 23.
Lead-in
Which, if
any, of the following statements is true in relation to reduced ovarian
reserve?
Statements
A.
|
AFC
<10 from both ovaries is indicative
|
B.
|
day 2 FSH <10 u/l is indicative
|
C.
|
ovarian volume <10 cm3 is indicative
|
D.
|
AFC and ovarian volume are accurate markers
|
E.
|
↓ AMH levels are indicative
|
Question 24.
Lead-in
Which of
following statements is true about predicting the age at the menopause?
Option List
A.
|
FSH
>30 u/l in the early follicular phase is the most useful predictor
|
B.
|
pre-auricular
dermal elasticity is the most useful predictor
|
C.
|
the
woman’s mother’s age at the menopause is the most useful predictor
|
D.
|
the AMH
level is the most useful predictor
|
E.
|
the AMH
level in conjunction with the woman’s age is the most useful predictor
|
Question 25.
Lead-in
Which of
the following statements are true of AMH levels and response to fertility
treatment?
Statements
A.
|
AMH
levels are strong indicators of the quantitative response to COS
|
B.
|
AMH levels help with tailoring COS protocols to the
individual
|
C.
|
about 10% of women have a poor response to COS
|
D.
|
high AMH levels justify the use of lower doses of FSH
|
E.
|
AMH levels are equivalent to basal FSH & inhibin as
predictors of quantitative response to COS
|
Question 26.
Lead-in
Which of
the following statements are true in relation to the pre-antral and antral
follicles?
Statements
A.
|
antrum
means “door” or “entrance”
|
B.
|
“pre-antral”
and “primordial” describe the same follicles
|
C.
|
pre-antral follicles show separate granulosa and luteal
layers
|
D.
|
pre-antral follicles are readily seen on ultrasound
|
E.
|
antral follicles have a fluid-filled cavity
|
Question 27.
Lead-in
Which of
the following statements are true about the incidence of OHSS?
Statements
A.
|
the
incidence varies with the type of ovarian stimulation used
|
B.
|
mild OHSS occurs in about 30% of conventional IVF
cycles
|
C.
|
moderate / severe OHSS occurs in about 1% of
conventional IVF cycles
|
D.
|
about 0.3% of women need hospitalisation for OHSS after
IVF
|
E.
|
OHSS does not occur with clomiphene use
|
Question 28.
Lead-in
Which of
the following statements are true?
Statements
A.
|
basal
AMH levels are increased in PCOS
|
B.
|
high basal levels of AMH are linked to an ↑ risk of
OHSS with ovarian stimulation
|
C.
|
low basal levels of AMH are linked to an ↑ risk of OHSS
with ovarian stimulation
|
D.
|
↑ BMI is linked to an ↑ risk of OHSS with ovarian
stimulation
|
E.
|
older age is linked to an ↑ risk of OHSS with ovarian
stimulation
|
Option List
1
|
A + B +
D + E
|
2
|
A + C +
D + E
|
3
|
A + B +
D
|
4
|
A + B +
E
|
5
|
A + C +
D
|
Question 29.
Lead-in
Which of
the following statements are true?
Statements
A.
|
there is
evidence of a +ve link between AMH levels and pregnancy rates
|
B.
|
there is evidence of a –ve link between AMH levels and
pregnancy rates
|
C.
|
AMH levels are a practical means of predicting
pregnancy rates
|
D.
|
AMH levels are best used with BMI in predicting pregnancy
rates
|
E.
|
AMH levels are best used with FSH levels in predicting
pregnancy rates
|
Question 30.
Lead-in
Which of
the following statements are true?
Option list
A.
|
PCOS is
associated with an increased basal AMH level
|
B.
|
PCOS is associated with a decreased basal AMH level
|
C.
|
elevated AMH levels are included in the diagnostic
criteria for PCOS
|
D.
|
reduced AMH levels are included in the diagnostic
criteria for PCOS
|
E.
|
PCOS-associated increase in antral follicle numbers
explains the ↑ AMH levels
|
Question 31.
Lead-in
Bhide et
al say that women with PCOS can be sub-divided into two groups which do no
overlap on the basis of AMH levels. Which of the following statements is true?
Statements
A.
|
Group 1
is linked to high AMH levels, high androgen levels, insensitivity to insulin
and anovulation
|
B.
|
Group 1 is linked to lower AMH levels, high androgen
levels, insensitivity to insulin and anovulation
|
C.
|
Group 2 is linked to high AMH levels, lower androgen
levels, better sensitivity to insulin and anovulation
|
D.
|
Group 2 is linked to lower AMH levels, lower androgen
levels, better sensitivity to insulin and ovulation
|
E.
|
None of the above
|
11
Basic communication skills. Role-play.
Candidate's Instructions.
You are a 5th. year SpR. You are about to see
Jane Tarzan. The GP letter reads as follows.
Tree-top House,
High Street,
Biblioville.
BV996OO.
Re: Jean Tarzan, DOB 17 August 1940,
16 High Rise Flats,
Biblioville.
Dear Doctor,
Mrs Tarzan reports some bleeding down below. She has got
up quite a head of steam about it, but she is a rather excitable type with a
strange husband who seems to spend most of his time communing with animals in
the local woods. Please advise.
John Lacklustre.
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