22nd. January 2018

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22^nd.  January 2018.

31	EMQ. MMRRACE & maternal mortality
32	SBA. Coeliac disease & pregnancy
33	EMQ. Cancer incidence & mortality
34	EMQ. Education
35	EMQ. Vulval conditions
36	SBA. Needle-stick and related injuries

31.         MMRRACE & maternal mortality

Abbreviations.

CEMD:  Confidential Enquiry into Maternal Death.

CE:         Confidential Enquiry.

CER:      Confidential Enquiry Report.

CHD:     Congenital heart disease.

CMACE:              Centre for Maternal and Child Enquiries (now defunct).

CODAC:              Causes of Death and Associated Conditions. Classification system for perinatal death.

EEG       electroencephalogram

FAST:    Focused Assessment with Sonography in Trauma.

HQIP:    Health Quality Improvement Partnership.

ICD-10: WHO’s International Classification of Diseases. Version 10 from 1990.

ICD-MM:            WHO’s use of ICD-10 for classification of maternal deaths.

ICNARC:              The Intensive Care National Audit and Research Centre.

MBRRACE:         MMBRACE-UK. Mothers and Babies - Reducing Risk through Audits and Confidential Enquiries across the UK.

MBRRACE14:     Saving Lives, Improving Mothers’ Care. 2009-12. Published December 2014.

MBRRACE15:     Saving Lives, Improving Mothers’ Care. 2011-13. Published December 2015.

MBRRACE16:     Saving Lives, Improving Mothers’ Care. 2012-14. Published December 2016.

MBRRACE17:     Saving lives, Improving Mothers’ Care. 2013-15. Published December 2017.

MMR:   Maternal mortality rate

MMRat Maternal mortality ratio.

MMRpt.              Maternal Mortality Report.

MMRpt06-8:      Maternal Mortality Report 2006-8: “Saving Mothers’ Lives. Reviewing maternal deaths to make motherhood safer: 2006-2008

NEAD    non-epileptic attack disorder

NMNIRP:            National Maternal, Newborn and Infant Review Programme

NPEU:   National Perinatal Epidemiology Unit at Oxford University.

SADS/MNH:       Sudden adult death syndrome with a morphologically normal heart.

SANDS: Stillbirth and Neonatal Death Society.

TIMMS: The Infant Mortality & Morbidity Studies at the University of Leicester.

UKOSS:                UK Obstetric Surveillance System run by the NPEU.

WWE:   women with epilepsy.

WWNEAD:         women with non-epileptic attack disorder

Question 1.        What is the meaning of the acronym MBRRACE-UK”?

Option list.

There is none, to make things more testing.

Question 2.        Which organisation does it replace?

Question 3.        How does it differ structurally from its predecessor?

Question 4.        How will the format of its reports differ from those of its predecessor?

Question 5.        When was MBRRACE’s first Report published?

Question 6.        What was unusual about MBRRACE’s first Report?

A	it covered three years, not two
B	it covered four years, not three
C	it was very amusing
D	it made serious criticisms of the funding of the NHS
E	it made serious criticisms of the hours worked by junior doctors
F	none of the above

Question 7.        What is ICD-MM?

A	ICD-10 as applied to maternal death
B	ICD-11 as applied to maternal death
C	International classification of maternal madness
D	International chocolate delice- Mmmmm!
E	none of the above

Question 8.        When was ICD-MM adopted by MBRRACE?

A	2014
B	2015
C	2016
D	ICD-MM does not exist
E	ICD-MM will be introduced in 2017
F	none of the above

Question 9.        What changes were made to the classification of maternal suicide by MBRRACE?

A	maternal suicide was reclassified as direct death
B	maternal suicide was reclassified as indirect death
C	maternal suicide was reclassified as late death as most occur > 6/52 post-delivery
D	maternal suicide was reclassified as coincidental, as most women were already very ill
E	maternal suicide was reclassified as irrelevant as these women were suicide-likely
F	none of the above

Question 10.     When  were the changes to the classification of maternal suicide made by MBRRACE?

A	2014
B	2015
C	2016
D	the changes are planned for 2017
E	no changes have been made and none are planned
F	none of the above

Question 11.     What geographical innovation was included in MBRRACE’s first Report?

Question 12.     What alterations were made to the timings of maternal death to be considered in its Reports?

Question 13.     What was the latest MMR reported by MBRRACE?

Question 14.     How did this compare with the final MMR reported  by CMACE?            

A	MMR was lower, but the difference was not statistically significant
B	MMR was lower and the difference was  statistically significant
C	MMR was higher, but the difference was not statistically significant
D	MMR was higher and the difference was statistically significant
E	MMR was similar

Question 15.     Which, if any, of the following topics were included in the confidential enquiries in the first MBRRACE Report in December 2014?

A	amniotic fluid embolism
B	epilepsy
C	haemorrhage
D	placenta accreta, increta & percreta
E	psychiatric causes

Question 16.     Which topics were reviewed in detail in the second Report in 2015?

Question 17.     Which topics were reviewed in detail in the third Report in 2016?

Question 18.     Which topics were reviewed in detail in the fourth Report in 2017?

Question 19.     What is the definition of a maternal death?

Question 20.     What is the definition of a direct maternal death?

Question 21.     What is the definition of indirect maternal death?

Question 22.     What was the leading direct cause of death in the first MBRRACE Report?

Question 23.     What was the leading indirect cause of death in the first Report?

Question 24.     What were the 5 top causes of direct maternal death in the triennium 2013-15?

Question 25.     What observation was made in the first Report about deaths due to hypertensive diseases?

Question 26.     Which condition was linked to 1 in 11 maternal deaths in the first Report in 2014?

Question 27.     What key messages were singled out in the first MBRRACE Report in 2014?

Question 28.     What key messages were singled out in the second MBRRACE Report in 2015?

Question 29.     What key messages were singled out in the third MBRRACE Report in 2016?

Question 30.     What messages relating to critical care were included in the third MBRRACE Report in 2016?

Question 31.     What is the definition of the maternal mortality rate?

Question 32.     What is the definition of a “maternity”?

Question 33.     What is the definition of a live birth?

Question 34.     What is the definition of a stillbirth?

Question 35.     What is the definition of the maternal mortality ratio?

Question 36.     How many maternal deaths in pregnancy or the 6 weeks after were due to epilepsy in 2013-15?

Option list.

A	5
B	8
C	23
D	34
E	41

Question 37.     Which, if any, of the following statements is true of the causes of death due to epilepsy in pregnancy in 2013-15?

Option list.

A	the main cause was asphyxia
B	the main cause was drowning in the bath
C	the main cause was falling
D	the main cause was intracranial bleeding
E	the main cause was status epilepticus
F	the main cause was SUDEP

Question 38.     Which, if any, of the following statements is true of the women who died due to epilepsy in pregnancy in 2013-15?

Option list.

A	90% had good pre-pregnancy control of the epilepsy
B	80% had good pre-pregnancy control of the epilepsy
C	70% had good pre-pregnancy control of the epilepsy
D	60% had good pre-pregnancy control of the epilepsy
E	50% had good pre-pregnancy control of the epilepsy
F	40% had good pre-pregnancy control of the epilepsy
G	30% had good pre-pregnancy control of the epilepsy
H	20% had good pre-pregnancy control of the epilepsy
J	10% had good pre-pregnancy control of the epilepsy
I	8 of the 9 did not have good control and the quality of control was unknown for the 9th.
K	None of the above

Question 39.     Which, if any, of the following statements is true of non-epileptic attack disorder (NEAD)  as discussed in MBRRACE17?

Option list.

A	is less common than epilepsy in pregnancy
B	is more common than epilepsy in pregnancy
C	is as common as epilepsy in pregnancy
D	NEAD is a diagnosis that should not be made in pregnancy
E	NEAD is most common in male adolescents
F	Most women with NEAD also have epilepsy

Question 40.     Which, if any, of the following statements is most appropriate to describe notification of the women who died due to epilepsy in pregnancy in 2013-15 to the UK Epilepsy and Pregnancy Register?

Option list.

A	>90%
B	80-890%
C	70-79%
D	60-69%
E	50-59%
F	40-49%
G	<30%
H	<25%
J	<20%
I	<10%
K	<5%

Question 41.     How many maternal deaths were due to cardiac causes in 2012-14?

Option list.

A	47
B	51
C	56
D	63
E	78
F	82
G	90

Question 42.     How many maternal deaths were due to cardiac causes in 2012-14?

Option list.

A	47
B	51
C	56
D	63
E	78
F	82
G	90

Question 43.     How many deaths due to cardiac causes were considered in detail in the Confidential Enquiry into cardiac deaths in the 2012-14 Report?

Option list.

A	35
B	48

Question 44.     What is the definition of a stillbirth?

Question 45.     What is the definition of the maternal mortality ratio?

Question 46.     How many maternal deaths were due to cardiac causes in 2012-14?

Option list.

A	47
B	51
C	56
D	63
E	78
F	82
G	90

Question 47.     How many deaths due to cardiac causes were considered in detail in the Confidential Enquiry into cardiac deaths in the 2012-14 Report?

Option list.

A	35
B	48
C	51
D	78
E	108
F	135
G	153
H	178
I	201

Question 48.     Which day was singled out as the most dangerous for cardiac death?

Option list.

A	the day of onset of labour
B	the 24 hours after the administration of a general anaesthetic in labour
C	the 24 hours after the delivery of a baby by Caesarean section
D	the 24 hours after instrumental delivery of a baby
E	the day of delivery
F	the day of delivery after the birth of the baby
G	the first day at home

Question 49.     What percentage of cardiac deaths took place on the day highlighted as the most dangerous?

Option list.

A	5%
B	10%
C	15%
D	20%
E	25%
F	30%

Question 50.     What were the three most common causes of cardiac death recorded in MBRRACE16?

Option list.

A	Aortic dissection
B	Congenital heart disease (CDH)
C	Hypertension
D	Ischaemic heart disease
E	Myocardial disease / cardiomyopathy
F	Other
G	Rheumatic heart disease.
H	SADS/MNH
I	Valvular heart disease

Question 51.     How many deaths due to congenital heart disease were recorded in MBRRACE16?

Option list.

A	0
B	3
C	5
D	11
E	15
F	24
G	35

Question 52.     What were the main causes of congenital heart disease deaths recorded in MBRRACE16?

Option list.

A	Aortic dissection
B	Aortic rupture
C	Left heart failure
D	Right heart failure
E	Pulmonary artery hypertension
F	Pulmonary vein hypertension
G	Valvular heart disease

Question 53.     Approximately what proportion of the women who died of cardiac disease in MBRRACE16 were known to have cardiac disease before the pregnancy?

Option list.

A	10%
B	20%
C	30%
D	40%
E	50%
F	60%
G	70%
H	80%
I	90%

Question 54.     What other risk factors were noted in MBRRACE16 in relation to the women who died of cardiac causes?

Option list.        There is no option list to make your life harder. But you know the risk factors!

Question 55.     What proportion of the cardiac deaths in MBRRACE16 occurred in ambulances or emergency departments?

Option list.

A	5%
B	10%
C	20%
D	30%
E	40%
F	50%

Question 56.     What “overall messages for future care” in relation to cardiac disease were included in MBRRACE16?

Option list. There is none.

Question 57.     How many deaths occurred due to aortic dissection in 2009-14?

Option list.

A	0
B	3
C	6
D	9
E	15
F	18
G	21
H	24
I	30

Question 58.     Which, if any of the following statements are true in relation to the deaths from aortic dissection in MBRRACE16?

Option list.

A	most occur in late pregnancy / puerperium, the risk being 25 times greater than at other times
B	the most common cause of death is tamponade
C	20 of the deaths involved the descending aorta
D	the classical symptom is severe chest pain radiating to the back
E	the classical symptom is severe chest pain radiating to the left arm
F	the classical symptom is severe chest pain radiating to the neck
G	most cases occurred in women with known aortopathy, especially Marfan’s syndrome
H	surgical repair of congenital, complex coarctation was identified as a risk factor.
I	8 of the 21 women had presented in the days before death but aortic dissection had not been considered
J	42% of the women died at home or before reaching the emergency department.
K	better care might have made a difference to the outcome in almost 60% of cases.

Question 59.     What were the “Key messages” about cardiovascular disease in MBRRACE16?

Option list.        There is none. Write as many as you know.

Question 60.     Acute coronary syndrome. I have written an EMQ about myocardial infarction. It has data from the UKOSS survey. https://www.ncbi.nlm.nih.gov/pubmed/22127355 and https://www.npeu.ox.ac.uk/research/ukoss-myocardial-infarction-136. I’ll add the data from MBRRACE 16 and put it in one of the tutorials..

Question 61.     Approximately how many women died of myocardial disease / cardiomyopathy?

Option list.

A	5
B	10
C	15
D	20
E	25

Question 62.     Approximately how many women died of peripartum cardiomyopathy?

Option list.

A	5
B	10
C	15
D	20
E	25

Question 63.     What type of cardiomyopathy is peripartum cardiomyopathy?

Option list.

A	congenital cardiomyopathy
B	dilated cardiomyopathy
C	hypertrophic cardiomyopathy
D	obesity-related cardiomyopathy
E	restrictive cardiomyopathy

Question 64.     With regard to cardiomyopathy, which symptom is singled out in MBRRACE 16 as particularly needing full investigation?

Option list.

A	angina
B	“drop” attacks
C	dyspnoea
D	nocturnal sweats
E	palpitations

Question 65       Which of the following are especially problematic for women with hypertrophic cardiomyopathy?

Option list.

A	bradycardia
B	epilepsy
C	hyperglycaemia
D	hypertension
E	hypotension
F	tachycardia

Question 66.     MBRRACE 16 records that investigation ceased once a particular diagnosis had been excluded in a number of cases of cardiovascular compromise and the women died later of undiagnosed cardiac disease. What was the diagnosis?

Option list.

A	acute coronary syndrome
B	aortic stenosis
C	atrial fibrillation
D	pulmonary embolism
E	ventricular fibrillation

Question 67.     When are women with peripartum cardiomyopathy most likely to die?

Option list.

A	1st. trimester
B	2nd. trimester
C	3rd. trimester
D	1st. stage of labour
E	2nd. stage of labour
F	3rd. stage of labour
G	1st. 24 hours after delivery
H	in the puerperium
I	from 6 weeks to 1 year after the delivery

Question 68.     Which, if any, of the following statements are true  in relation to obesity-related cardiomyopathy (ORC) ?

Option list.

A	ORC is not a recognised condition
B	MBRRACE16 reported 2 deaths from ORC
C	ORC is associated with cardiac enlargement
D	ORC is associated with fatty infiltration of the ventricular muscle
E	is characterised by myocyte depletion and left ventricular hypoplasia
F	is characterised by myocyte hypertrophy and left ventricular hypertrophy

Question 69.     How many deaths were due to valvular heart disease ?

Option list.

A	1
B	2
C	3
D	4
E	5
F	6
G	7
H	8
I	9
J	10
K	11

Question 70.     Why am I going to write a separate EMQ on valvular heart disease?

Option list.

A	I am now bored with this topic
B	I find it so fascinating that I feel it deserves its own EMQ
C	I don’t know enough about it and need to do some research
D	UKOSS conducted a study from 2013 – 2015 and this needs to be included
E	none of the above.

Question 71.     What were the key messages re hypertensive disease in MBRRACE16?

Option list. There is none. Write as many as you can think of.

Question 72.     Which, if any, of the following was the most common cause of death from hypertensive disease in 2009-14?

Option list.

A	acute fatty liver of pregnancy
B	eclampsia / cerebral oedema
C	haemorrhage due to thrombocytopenia
D	HELLP /hepatic necrosis
E	hepatic rupture
F	intracranial haemorrhage
G	left ventricular failure
H	pulmonary oedema

Question 73.     Which, if any, of the following conditions does MBRRACE16 say are usually attributable to poor fluid management?

Option list.

A	acute fatty liver of pregnancy
B	eclampsia / cerebral oedema
C	haemorrhage due to thrombocytopenia
D	HELLP /hepatic necrosis
E	hepatic rupture
F	intracranial haemorrhage
G	left ventricular failure
H	pulmonary oedema

Question 74.     What upper gestational limit was used by MBRRACE16 in the definition of early pregnancy?

Option list.

A	10 weeks
B	12 weeks
C	16 weeks
D	18 weeks
E	20 weeks
F	24 weeks
G	26 weeks

Question 75.     Which of the following ranked top in the causes of death < 24 weeks in 2009-2014?

Option list.

A	Cardiac
B	Ectopic
C	Haemorrhage
D	Mental health problems
E	Miscarriage
F	Sepsis
G	Thrombosis & thrombo-embolism
H	TOP

Question 76.     Why did MBRRACE16 recommend FAST for women presenting to emergency departments with pulmonary embolism in the list of differential diagnoses?

Option list.

A	to exclude aortic dissection before thrombolysis
B	to exclude acute coronary syndrome before thrombolysis
C	to exclude intra-peritoneal bleeding from ectopic pregnancy before thrombolysis
D	to exclude intra-uterine pregnancy before thrombolysis
E	to exclude Bornholm disease before thrombolysis

Question 77.     What were the key messages in relation to early pregnancy deaths in MBRRACE16?

Option list. There is none. Write as many as you can think of.

Question 78.     What proportion of pregnant / recently delivered women needing critical care survive?

Option list.

A	50%
B	60%
C	70%
D	80%
E	90-94%
F	≥ 95%

Question 79.     MBRRACE16 looked at the cause of death in 144 women admitted to critical care from 2009-14. What was the most common cause of death?

Option list.

A	Amniotic fluid embolism
J	Anaesthetic
I	Cardiac
L	Coincidental
B	Early pregnancy death
D	Haemorrhage
E	Neurological
K	Other indirect
C	PET / eclampsia
H	Psychiatric
G	Sepsis
F	Thrombosis / thrombo-embolism
M	Unascertained

Question 80.     What are the key facts to remember about critical care?

Option list. There is none. Write what you think are the key facts and numbers.

Question 81.     What “red flags” does MBRRACE highlight in relation to maternal sepsis?

Option list. There is none.

* There was a query in the January 2017 tutorial about whether the upper limit of lactate of 2 or 4. MBRRACE14 has the following on page 34: “serum lactate  >2mmol/L indicates severe sepsis

and > 4mmol/L indicates septic shock”.

MBRRACE16 in Box 6.1 which lists maternal sepsis red flags includes lactate ≥2 mmol/l.

Question 82.     What were MBRRACE16’s “key messages” for critical care?

Option list.

* There was a query in the January 2017 tutorial about whether the upper limit of lactate of 2 or 4. MBRRACE14 has the following on page 34: “serum lactate  >2mmol/L indicates severe sepsis

and > 4mmol/L indicates septic shock”.

MBRRACE16 in Box 6.1 which lists maternal sepsis red flags includes lactate ≥2 mmol/l.

Question 83.     What were MBRRACE16’s “key messages” for critical care?

Question 84.     The following topics were covered in the first 3 MBRRACE Reports? Sort them by Report: 1^st. Report 2014, 2^nd. Report 2015, 3^rd. Report 2016.

AFE,
anaesthesia,
cardiac causes,
coincidental deaths,
early pregnancy deaths,
eclampsia & PET,
haemorrhage,
late deaths,
malignancy,
neurological disorders,
psychiatric causes,
respiratory, endocrine and other indirect causes,
sepsis.
thrombosis and thromboembolism.
women admitted to critical care
women with artificial heart valves

Question 85.     How many anaesthetic deaths were recorded in MBRRACE17?

Option list.

A	1
B	2
C	5
D	8
E	10
F	12

Question 86.     Which, if any,  of the following statements are included by MBRRACE17?

Option list.

A	BP is the best measure of cardiac output
B	pulse rate is a good indicator of cardiac output
C	external cardiac compressions should be started early if cardiac output is inadequate
D	external cardiac compressions are contraindicated in the presence of cardiac activity because of the risk of ventricular rupture
E	if there has been massive haemorrhage, extubation should not be done until the bleeding has ceased and adequate resuscitation has taken place.

Question 87.     Which of the following sizes of endotracheal tubes are recommended for inclusion in resuscitation carts by MBRRACE17?

Option list.

A	4 mm
B	5 mm
C	6 mm
D	7 mm
E	8 mm
F	9 mm

32.         Coeliac disease & pregnancy

Abbreviations.

AGA:                            anti-gliadin antibodies 

CD:                              coeliac disease.

EMA:                           anti-endomysial antibodies. 

FGR:                            Fetal growth restriction.

IgA:                              immunoglobulin A IgG. 

tTGA:                           anti-tissue transglutaminase antibody.

Question 1.

Lead-in

What is coeliac disease?

Option List

A.	allergy to gluten
B.	malabsorption due to large bowel inflammation
C.	an auto-immune disorder triggered by gluten sensitivity causing villous atrophy of the descending colon in individuals with a genetic predisposition
D.	an auto-immune disorder triggered by gluten sensitivity causing villous atrophy of the gastric mucosa in individuals with a genetic predisposition
E.	an auto-immune disorder triggered by gluten sensitivity causing villous atrophy of the small bowel in individuals with a genetic predisposition

Question 2.

Lead-in

What is the prevalence of coeliac disease in women of reproductive age?

Option List

A.	0.1%
B.	0.5%
C.	1-2 %
D.	2-5%
E.	5-10%

Question 3.

Lead-in

Which of the following groups have an increased risk of CD?

Option List

A.	1st. degree relatives of those with CD
B.	those with type 1 diabetes
C.	those with iron deficiency anaemia
D.	those with osteoporosis
E.	those with unexplained infertility

Question 4.

Lead-in

Which of the following are features of CD in the non-pregnant population?

Option List

A.	abdominal bloating and pain
B.	amenorrhoea
C.	anaemia
D.	recurrent miscarriage
E.	unexplained infertility

Question 5.

Lead-in

How do pregnant women with CD present most commonly?

Option List

A	anaemia
B	failure to gain weight in pregnancy
C	intra-uterine growth retardation
D	low BMI
E	no recognised abnormality

Question 6.

Lead-in

Which of the following commonly occur in pregnant women with CD?

Option List

A	anaemia
B	failure to gain weight in pregnancy
C	intra-uterine growth retardation
D	low BMI
E	no recognised abnormality

Question 7.

How should the woman with suspected CD be investigated initially?

Option List

A.	jejunal biopsy
B.	IgA EMA
C.	IgA tTGA
D.	IgA EMA + IgA tTGA
E.	rectal biopsy

Question 8.

Lead-in

Which, if any, of the following statements are true in relation to the woman due to have testing for suspected CD?

Option List

A.	continue with a normal diet.
B.	continue with a normal diet that includes a minimum of 5 gm. gluten daily
C.	continue with a normal diet that includes a minimum of 10 gm. gluten daily
D.	follow a strict gluten-free diet for at least 1 month
E.	follow a strict gluten-free diet for at least 3 months

Question 9.

Lead-in

Which of the following conditions should make consideration of testing for CD sensible?

Option List

A.	amenorrhoea
B.	Down’s syndrome
C.	epilepsy
D.	recurrent miscarriage
E.	Turner’s syndrome
F.	unexplained infertility

Question 10.

Lead-in

How is the diagnosis of CD confirmed after +ve serological testing?

Option List

A.	colonoscopy
B.	enteroscopy
C.	gastroscopy
D.	rectal biopsy
E.	small bowel  biopsy

Question 11.

Lead-in

Which skin condition is particularly associated with CD?

Option List

A.	atopic eczema
B.	dermatitis herpetiformis
C.	dermatitis multiforme
D.	dermatographia
E.	psoriasis

Question 12.

Lead-in

Which of the following are likely to be absorbed less well than normally in women with CD?

Option List

A.	carbohydrate
B.	fat
C.	folic acid
D.	protein
E.	vitamins B12, D & K

Question 13.

Lead-in

What is the appropriate treatment of CD?

Option List

A.	antibiotics: long-term in low-dosage
B.	azathioprine
C.	cyclophosphamide
D.	rectal steroids
E.	none of the above

Question 14.

Lead-in

Which of the following do not contain gluten?

Option List

A.	barley
B.	oats
C.	rapeseed oil
D.	rye
E.	wheat

33.         Cancer incidence & mortality

These questions relate to the incidence of female cancer and associated mortality.

Pick one option from the option list.

Abbreviations.

NHL:      non-Hodgkin Lymphoma

Question 1.

Lead-in

Which is the most common female cancer?

Option List

F.	Bowel
G.	Breast
H.	Cervix
I.	Endometrium
J.	Lung

Question 2.

Lead-in

Which is the 2^nd. most common female cancer?

Option List

A.	Bowel
B.	Breast
C.	Cervix
D.	Endometrium
E.	Lung

Question 3.

Lead-in

Which is the 3^rd. most common female cancer?

Option List

A.	Bowel
B.	Breast
C.	Cervix
D.	Endometrium
E.	Lung

Question 4.

Lead-in

Which is the 4^th. most common female cancer?

Option List

A.	Bowel
B.	Cervix
C.	Endometrium
D.	Lung
E.	Pancreas

Question 5.

Lead-in

Which is the 5^th. most common female cancer?

Option List

A.	Cervix
B.	Malignant melanoma
C.	Non-Hodgkin’s lymphoma
D.	Ovary
E.	Vulva

Question 6.

Lead-in

Which is the 6^th. most common female cancer?

Option List

A.	Cervix
B.	Malignant melanoma
C.	Non-Hodgkin’s lymphoma
D.	Ovary
E.	Vulva

Question 7.

Lead-in

Where does cervical cancer feature in the list of the most common female cancers?

Option List

A.	10th.
B.	11th.
C.	15th.
D.	20th.
E.	24th.

Question 8.

Lead-in

Where does vulval cancer feature in the list of the most common female cancers?

Option List

A.	10th.
B.	12th.
C.	16th.
D.	20th.
E.	none of the above

Question 9.

Lead-in

Which is the most common cancer causing female death in the UK?

Option List

F.	Breast
G.	Bowel
H.	Lung
I.	Ovary
J.	Pancreas

Question 10.

Lead-in

Which is the 2^nd. most common cancer causing female death in the UK?

Option List

A.	Breast
B.	Bowel
C.	Lung
D.	Ovary
E.	Pancreas

Question 11.

Lead-in

Which is the 3^rd. most common cancer causing female death in the UK?

Option List

A.	Breast
B.	Bowel
C.	Lung
D.	Ovary
E.	Pancreas

Question 12.

Lead-in

Which is the 4^th. most common cancer causing female death in the UK?

Option List

A.	Brain
B.	Oesophagus
C.	Ovary
D.	Pancreas
E.	Uterus

Question 13.

Lead-in

Which is the 5^th. most common cancer causing female death in the UK?

Option List

A.	Brain
B.	Oesophagus
C.	Ovary
D.	Pancreas
E.	Uterus

Question 14.

Which is the 6^th. most common cancer causing female death in the UK?

Option List

A.	Brain
B.	Oesophagus
C.	Ovary
D.	Pancreas
E.	Uterus

Question 15.

Lead-in

The incidence of cervical cancer has fallen from the late 1970s until now. What is the approximate figure for the fall?

Option List

A.	10%
B.	25%
C.	50%
D.	60%
E.	75%

Question 16.

Lead-in

The incidence of cervical cancer fell in the past decade. What is the approximate figure for the fall?

Option List

A.	5%
B.	10%
C.	15%
D.	20%
E.	25%

Question 17.

Lead-in

What proportion of cervical cancer is diagnosed in women < 45 years?

Option List

A.	20%
B.	30%
C.	40%
D.	50%
E.	60%

Question 18.

Lead-in

When was routine HPV vaccination of girls introduced in the UK?

Option List

A.	2000
B.	2002
C.	2004
D.	2006
E.	2008

Question 19.

Lead-in

From what year might we expect to see a reduction in cervical cancer incidence as a result of the HPV vaccination programme?

Option List

A.	2020
B.	2025
C.	2030
D.	2040
E.	2050

Question 20.

Lead-in

When was routine HPV vaccination of boys introduced in the UK?

Option List

A.	2010
B.	2011
C.	2012
D.	2014
E.	None of the above

34.         Education

Option list.

1. brainstorming.
2. brainwashing
3. cream cake circle.
4. Delphi technique.
5. demonstration & practice using clinical model.
6. doughnut round.
7. interactive lecture with EMQs.
8. lecture.
9. 1 minute preceptor method.
10. teaching peers / junior colleagues
11. schema activation.
12. schema refinement.
13. small group discussion.
14. snowballing.
15. snowboarding.
16. true
17. false

Scenario 1.

A woman is admitted with an eclamptic seizure. The acute episode is dealt with and she is put on an appropriate protocol. You wish to use the case to outline key aspects of PET and eclampsia to the two medical students who are on the labour ward with you. Which would be the most appropriate approach?

Scenario 2.

You have been asked to provide a summary of the key aspects of the recent Maternal Mortality Meeting to the annual GP refresher course. There are likely to be 100 attendees. Which would be the most appropriate approach?

Scenario 3.

You have been asked to teach a new trainee the use of the ventouse. Which would be the most appropriate approach?

Scenario 4.

You have been asked to teach a group of medical students about PPH. To your surprise you find that they have good basic knowledge. Which technique will you apply to get the most from the teaching session?

Scenario 5.

Your consultant has asked you to get the unit’s medical students to prepare some questions about breech delivery which they can ask of their peers when they next meet. Which technique will you use?

Scenario 6.

You have been asked to discuss 2ry. amenorrhoea with your unit’s medical students. You are uncertain about the amount of basic physiology and endocrinology they remember from basic science teaching. Which technique will you use?

Scenario 7

The RCOG has asked you to chair a Green-top Guideline development committee. You find that there is very little by way of research evidence to help with the process. The College has assembled a team of consultants with expertise and interest in the subject. Which technique would be best to reach consensus on the various elements of the GTG?

Scenario 8

Which of the listed teaching techniques is least likely to lead to deep learning?

Scenario 9

An interactive lecture with EMQs is the best method of teaching. True or false.

Scenario 10

Only 20% of what is taught in a lecture is retained. True or false.

Scenario 11.

The main role of the teacher is information provision. True or false.

Scenario 12.

The main role of the teacher is to be a role model.  True or false.

35.         Vulval conditions

Lead-in.

The following scenarios relate to vulval conditions.

Choose the most likely vulval condition from the option list.

Option list.

A.	Acne.
B.	Behçet’s syndrome.
C.	Candidiasis.
D.	CIN 3
E.	CIN1
F.	Crohn’s disease.
G.	Dermatitis.
H.	Eczema.
I.	Genital warts.
J.	Hidradenitis suppurativa.
K.	Leprosy.
L.	Lichen planus
M.	Lichen sclerosis
N.	Lymphogranuloma venereum
O.	Normal skin.
P.	Psoriasis.
Q.	Seborrhoeic dermatitis.
R.	Type 1 diabetes mellitus
S.	Type 2 diabetes mellitus
T.	Ulcerative colitis.
U.	VIN III.

Scenario 1.

A 22 year-old woman attends the colposcopy clinic after 2 smears showing minor atypia. The cervical appearances are of aceto-white with punctation. 

Scenario 2.

A 60-year old woman has an erythematous rash of the vulva extending to the inner thighs. A similar rash is noted under the breasts. She is not known to have diabetes.

Scenario 3.

A woman attends the gynaecology clinic with a vulval rash. It has a “lacy” appearance.  

Scenario 4.

A 35-year old woman attends is noted to have a vulval fistula. She has a history of episodic diarrhoea. 

Scenario 5.

A 25-year old woman attends the gynaecology clinic with a history of intense vulval itching and soreness. The appearances are of diffuse erythema with excoriation. Diabetes, candidiasis and other local infections have been eliminated by the GP. 

Scenario 6.

A 35-year old woman attends the gynaecology clinic with vulvitis. She also has a scalp rash. Clinical examination shows scaly, pink patches with signs of excoriation. Skin samples grow Malassezia ovalis.

Scenario 7.

A 40-year old woman has evidence of chronic vulval ulceration. She has recently been seen by a dermatologist for mouth ulceration and has been started on thalidomide.

Scenario 8.

An African woman of 35 years attends the gynaecology clinic. She has a ten-year history of chronic vulval ulceration. Examination shows multiple, tender vulval and pubic subcutaneous nodules, some of which have ulcerated.

Scenario 9.

A Caucasian woman of 29 years attends the gynaecology clinic with a chronic vulval rash. Examination shows erythematous areas with clearly defined margins and white scaly patches. 

Scenario 10.

A 30-year old woman attends the gynaecology clinic with vulval itching. Examination shows erythema of the labia minora and perineum. Full-thickness biopsy shows abnormal cell maturation throughout the epithelium with increased mitotic activity.

Scenario 11.

Which condition is described in GTG58 as presenting with polygonal lesions?

Scenario 12.

Which condition is described in GTG58 as presenting with “well-demarcated, glazed erythema around the introitus?

Scenario 13.

What is the aetiology of lichen planus?

36.         Needle-stick and related injuries

Abbreviations.

CMV:    cytomegalovirus

GBCV:   GB virus C

HAV:     hepatitis A virus

HBV:     hepatitis B virus

HCV:     hepatitis C virus

HDV:     hepatitis D virus

SOE:      significant occupational exposure to blood-borne infective agent.

TTV:      transfusion-transmitted virus

VL:         viral load.

Question 1.

Lead-in

Approximately how many SOEs are reported annually in the UK?

Option List

K.	~    100
L.	~    250
M.	~    500
N.	~ 1,000
O.	~ 5,000

Question 2.

Lead-in

Who was Ignac Phillip Semmelweis?

Option List

F.	the person credited with demonstrating the infective nature of puerperal sepsis
G.	the horticulturist who first grew the white flower subsequently popularised in the musical, “The sound of music”, naming it after his first wife, Eidel.
H.	the person who first used antisepsis in aerosol form to reduce the risk of infection during  C. section.
I.	the inventor of catgut sutures
J.	the inventor of the Dalkon shield

Question 3.

Lead-in

Why does the name of Semmelweis’s colleague Kotecha live on in medical history?

Option List

F.	he was the first doctor to perform hysterectomy
G.	he was the first doctor know to undergo transgender surgery
H.	he died of infection akin to puerperal sepsis after a SOE
I.	he performed the first successful repair of a 3rd. degree perineal tear
J.	none of the above

Question 4.

Lead-in

Which of the following have been described as causing infection after a SOE.

Infective agents

1.	hepatitis A virus
2.	hepatitis B virus
3.	hepatitis C virus
4.	human T cell leukaemia virus
5.	malaria parasites

Option List

A.	1 + 2 + 3 + 4 + 5
B.	1 + 2 + 3 + 5
C.	2 + 3 + 4 + 5
D.	2 + 3 + 4
E.	2 + 3 + 5

Question 5.

Lead-in

Which are the main causes of infection to cause concern in the UK in relation to SOEs?

Infective agents.

1.	hepatitis A virus
2.	hepatitis B virus
3.	hepatitis C virus
4.	HIV
5.	treponema pallidum

Option List

A.	1 + 2 + 3 + 4 + 5
B.	1 + 2 + 3 + 4
C.	1 + 2 + 3 + 5
D.	2 + 3 + 4 + 5
E.	2 + 3 + 4

Question 6.

Lead-in

Which group features most in the list of those reporting SOEs?

Option List

K.	doctors
L.	midwives
M.	phlebotomists
N.	nurses
O.	other healthcare workers

Question 7.

Lead-in

Which clinical activity generates most SOEs?

Option List

A.	acupuncture
B.	assisting in the operating theatre
C.	intramuscular drug / vaccine injection
D.	subcutaneous drug / vaccine injection
E.	venepuncture

Question 8.

Lead-in

Approximately how many cases of HIV seroconversion after SOE were recorded in the UK between 2004 and 2013?

Option List

F.	0
G.	1
H.	20
I.	100
J.	500

Question 9.

Lead-in

Rate the following body fluids as: high or low risk in relation to infectivity.

Option List

A.	amniotic fluid
B.	blood
C.	breast milk
D.	cerebro-spinal fluid
E.	faeces
F.	peritoneal fluid
G.	saliva
H.	urine
I.	urine – blood stained
J.	vaginal fluid
K.	vomit

Question 10.

Lead-in

Rate the following types of contact with body fluids as:

high-risk

low-risk

minimal or zero risk

Answer

A.	exposure to faeces: not bloodstained
B.	exposure to saliva: not bloodstained
C.	exposure to urine: not bloodstained
D.	exposure to vomit: not bloodstained
E.	exposure via broken skin
F.	exposure via intact skin
G.	injury deep, percutaneous
H.	exposure via mucosa
I.	injury superficial
J.	needle not used on source’s blood vessels
K.	needle used on source’s blood vessels
L.	sharps old
M.	sharps recently used
N.	sharps with blood not visible
O.	sharps with blood visible sharps

Question 11.

Lead-in

Rate the following types of sources of potentially infective body fluids as:

high-risk

low-risk

minimal or zero risk

Answer

A.	infected but VL and treatment details unknown
B.	recent blood test negative for all relevant viruses
C.	source has known risk factors but recent tests negative
D.	viral status not known but source has known risk factors
E.	viral status not known but source has no known risk factors
F.	VL detectable
G.	VL not detectable
H.	VL unknown but on treatment with good adherence

Question 12.

Lead-in

Approximately how many cases of HBV seroconversion after SOE have been recorded in the UK since 1997?

Option List

A.	0
B.	1
C.	20
D.	100
E.	500

Question 13.

Lead-in

Approximately how many cases of HCV seroconversion after SOE have been recorded in the UK since 1997?

Option List

A.	0
B.	1
C.	20
D.	100
E.	500

Question 14.

Lead-in

What is the estimated risk of transmission of infection of HBV in a SOE involving sharps in a patient +ve for HBe antigen?

Option List

	1 in 2
	1 in 3
	1 in 30
	1 in 300
	1 in 1,000 or less

Question 15.

Lead-in

What is the estimated risk of transmission of infection of HCV in a SOE involving sharps?

Option List

	1 in 2
	1 in 3
	1 in 30
	1 in 300
	1 in 1,000 or less

Question 16.

Lead-in

What is the estimated risk of transmission of infection of HIV in a SOE involving sharps?

Option List

	1 in 2
	1 in 3
	1 in 30
	1 in 300
	1 in 1,000 or less

Question 17.

Lead-in

What is the estimated risk of transmission of infection of HIV in a SOE involving mucosal splashing?

Option List

	1 in 2
	1 in 3
	1 in 30
	1 in 300
	1 in 1,000 or less

Question 18.

Lead-in

Which of the following carries the highest risk of transmission of an infective agent after a SOE.

Option List

A.	a bite on the bottom by an HIV-infected patient who finds your buttocks irresistible
B.	deep injury from a scalpel wielded by a psychopathic surgeon
C.	deep needle-stick after venepuncture
D.	spitting by a patient with HIV
E.	splash SOE from beating a disagreeable patient round the head with a frozen turkey because you are sick to death of their whingeing and perennial misery

Question 19.

Lead-in

List the steps you would take in relation to immediate first aid, including the things that might be suggested but you know are contraindicated.

Question 20.

Lead-in

Which tests should be performed on the source after obtaining consent?

List what you think should be done.

Option List

A.	HBV surface antigen
B.	HCV antibody
C.	HCV RNA
D.	HIV antigen and antibody (fourth generation HIV immunoassay)
E.	TTV antibody

Question 21.

Lead-in

What consent is required from the source individual?

Option List

A.	consent to having the tests
B.	consent to having the results given to the occupational health department
C.	consent to having the results given to the person who sustained the SOE
D.	consent to having the results given to the hospital’s legal team
E.	consent to notifying the hospital staff if the results are +ve.

Question 22.

Lead-in

What tests should be done on the person who has sustained the SOE and there is a significant risk of infection?

Option List

A.	a baseline sample should be taken and stored for possible future use
B.	HBV surface antibody
C.	HCV antibody
D.	HIV antigen and antibody

Question 23.

Lead-in

If there is a significant risk of HIV transmission, which of the following statements are correct in relation to when should PEP be given?

Option List

A.	before the results of the tests done on the source are available
B.	after the results of the tests done on the source are available
C.	as soon as is practical
D.	within 24 hours
E.	within 72 hours

Question 24.

Lead-in

What are the recommended drugs for PEP in the UK?

Option List

A.	Kaletra (200 mg lopinavir and 50 mg ritonavir)
B.	Raltegravir 400 mg twice daily
C.	Rifampicin 450-600mg daily as a single dose
D.	Tenofovir + lamivudine or emtricitabine
E.	Truvada (245 mg tenofovir disoproxil fumarate and 200 mg emtricitabine)

Question 25.

Lead-in

Which of the following statements are correct in relation to PEP in early pregnancy

Option List

A.	PEP is contraindicated until after 12 weeks
B.	PEP should be started as for the non-pregnant
C.	PEP should be started, but TOP should be offered
D.	PEP should be started, but not until the puerperium

Question 26.

Lead-in

Which of the following statements is true in relation to reducing the risk of HCV infection.

Option List

A.	HCV vaccine is safe in pregnancy and should be offered immediately
B.	HCV vaccine is a live vaccine and contraindicated in pregnancy
C.	acyclovir is an effective drug for prophylaxis
D.	there is no known effective prophylactic drug
E.	early treatment of HCV infection is effective, so SOE staff should be closely followed up for evidence of infection.