MRCOG tutorial Monday 23rd. June 2025

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23 June 2025.

54	Talk. Medical examiners and medical certificates of death
55	Viva. Exam favourite – topic revealed on the night
56	EMQ. Abortion Act
57	MCQ. The Coombs test
58	SBA. Fetal origins of adult disease
59	EMQ. Caffeine and pregnancy
60	SBA. Kisspeptin
61	EMQ. Marfan syndrome

 

Abbreviations.

NHSME:     NHS: Medical Examiners.

Fletcher:    First National Medical Examiner: Alan Fletcher. 2019.

 

Scenario 54.      Medical examiners and medical certificates of death.

Medical examiners started in the UK in 2019 with the appointment of Alan Fletcher who had many years of experience in certification of death. He was an A&E consultant, a useful fact for a viva - medical examiners can come from any specialty. A simple exam question would be “what are the qualifications needed by a medical examiner?”.

The topic is ‘hot’ as the medical examiner scheme was made mandatory in 2024 and extended to all deaths from just hospital deaths and there were significant changes to medical certification in 2024. All of this is very new, so most people don’t know much about it. Fortunately, there are only a few basic facts and some interesting history to get you up to speed. It will be a short talk, 15 minutes or so, not like the marathon of maternal mortality!

 

Scenario 55. Viva. The topic is an exam regular which I’ll reveal during the tutorial conditions.

 

Scenario 56. Abortion Act. Might seem bureaucratic, but gets asked.

Scenario 1. How many abortions were performed on residents of E&W aged 15-44 in 2020?

A	about 50,000
B	about 100,000
C	about 150,000
D	about 200,000
E	about 250,000
F	> 250,000

Scenario 2. What was the approximate rate of abortion in E&W residents in 2020?

A	1 per 1,000 resident women aged 15-44
B	10 per 1,000 resident women aged 15-44
C	15 per 1,000 resident women aged 15-44
D	25 per 1,000 resident women aged 15-44
E	50 per 1,000 resident women aged 15-44
F	100 per 1,000 resident women aged 15-44

Scenario 3. The rate of abortion in residents of E&W has declined by >20% from 2008-2020.

A	False
B	Haven’t a clue
C	Maybe
D	No data exist
E	True

Scenario 4. What proportion of TOPs were performed at gestations <10 weeks in E&W in 2020?

A	50%
B	60%
C	70%
D	80%
E	90%

Scenario 5. There was a significant improvement in the proportion of TOPs performed early from 2008-2020.

A	False
B	Haven’t a clue
C	Maybe
D	No data exist
E	True

Scenario 6. What % of abortions were performed after 24 weeks in 2020?

A	< 1%
B	1 - 3%
C	4 - 6%
D	7 - 9%
E	≥ 10%

Scenario 7. What proportion of TOPs were performed using medical techniques in 2020?

A	20%
B	30%
C	40%
D	50%
E	60%
F	70%
G	80%

Scenario 8. Which age group had the highest rate of TOP in 2020?

A	18
B	19
C	20
D	21
E	22
F	23
G	24
H	25

Scenario 9. What happened to the rate of TOP in 2020 for girls <18 years compared with 2008?

A	the rate was much lower
B	the rate was slightly lower
C	the rate was much higher
D	the rate was slightly higher
E	the rate was unchanged

Scenario 10. What happened to the rate of TOP in 2020 for girls <16 years compared with 2006?

A	the rate was much lower
B	the rate was slightly lower
C	the rate was much higher
D	the rate was slightly higher
E	the rate was unchanged

Scenario 12. Approximately what proportion of women having TOP in 2020 had previously had one or more TOPs?

A	1%
B	5%
C	10%
D	20%
E	30%
F	40%
G	50%

Scenario 13. What age group of women 1n 2020 were most likely to have had previous TOP?

	Age
A	< 18
B	18-19
C	20-24
D	25-29
E	30-34
F	≥ 35

Scenario 14. There were 185,824 TOPs in 2015. How many deaths occurred?

A	0 - 9
B	10 - 19
C	20 - 39
D	40 - 59
E	≥ 60

Scenario 15. What was the rate of significant complications of TOP in 2020?

A	<1%
B	1%
C	3%
D	5%
E	10%

Scenario 16. The RCOG recommends that women having TOP should have chlamydia screening. What proportion of women had this done in 2020?

A	<10%
B	10- 24%
C	25- 49%
D	50- 79%
E	80- 89%
F	≥ 90%

Scenario 17. The Abortion Act gives a number of legal grounds for TOP. Which of the following is listed as “1 (1) a”?

1	that the pregnancy has not exceeded its 24th. week and that the continuance of the pregnancy would involve risk, greater than if the pregnancy were terminated, of injury to the physical or mental health of the pregnant woman or any existing children of her family
2	the pregnancy has not exceeded its 24th. week and that the continuance of the pregnancy would involve risk, greater than if the pregnancy were terminated, of injury to the physical or mental health of any existing children of the family of the pregnant woman
3	the continuance of the pregnancy would involve risk to the life of the pregnant woman greater than if the pregnancy were terminated
4	the termination is necessary to prevent grave permanent injury to the physical or mental health of the pregnant woman
5	there is a substantial risk that if the child were born it would suffer from such physical or mental abnormalities as to be seriously handicapped

Scenario 18. The Abortion Act gives a number of legal grounds for TOP. Which of the following is listed as “1 (1) b”?

1	that the pregnancy has not exceeded its 24th. week and that the continuance of the pregnancy would involve risk, greater than if the pregnancy were terminated, of injury to the physical or mental health of the pregnant woman or any existing children of her family
2	the continuance of the pregnancy would involve risk to the life of the pregnant woman greater than if the pregnancy were terminated
3	the termination is necessary to prevent grave permanent injury to the physical or mental health of the pregnant woman
4	there is a substantial risk that if the child were born it would suffer from such physical or mental abnormalities as to be seriously handicapped
5	none of the above

Scenario 19. The Abortion Act gives a number of legal grounds for TOP. Which of the following is listed as “1 (1) c.

1	that the pregnancy has not exceeded its 24th. week and that the continuance of the pregnancy would involve risk, greater than if the pregnancy were terminated, of injury to the physical or mental health of the pregnant woman or any existing children of her family
2	the continuance of the pregnancy would involve risk to the life of the pregnant woman greater than if the pregnancy were terminated
3	the termination is necessary to prevent grave permanent injury to the physical or mental health of the pregnant woman
4	there is a substantial risk that if the child were born it would suffer from such physical or mental abnormalities as to be seriously handicapped
5	none of the above

Scenario 20. The Abortion Act gives a number of legal grounds for TOP. Which of the following is listed as “1 (1) d”?

1	that the pregnancy has not exceeded its 24th. week and that the continuance of the pregnancy would involve risk, greater than if the pregnancy were terminated, of injury to the physical or mental health of the pregnant woman or any existing children of her family
2	the continuance of the pregnancy would involve risk to the life of the pregnant woman greater than if the pregnancy were terminated
3	the termination is necessary to prevent grave permanent injury to the physical or mental health of the pregnant woman
4	there is a substantial risk that if the child were born it would suffer from such physical or mental abnormalities as to be seriously handicapped
5	none of the above

Scenario 21. The Abortion Act gives a number of legal grounds for TOP. Which of the following is listed as “1 (1) e”?

1	the pregnancy has not exceeded its 24th. week and that the continuance of the pregnancy would involve risk, greater than if the pregnancy were terminated, of injury to the physical or mental health of the pregnant woman
2	the pregnancy has not exceeded its 24th. week and that the continuance of the pregnancy would involve risk, greater than if the pregnancy were terminated, of injury to the physical or mental health of any existing children of the family of the pregnant woman
3	the continuance of the pregnancy would involve risk to the life of the pregnant woman greater than if the pregnancy were terminated
4	the termination is necessary to prevent grave permanent injury to the physical or mental health of the pregnant woman
5	there is a substantial risk that if the child were born it would suffer from such physical or mental abnormalities as to be seriously handicapped
6	none of the above

Scenario 22. With regard to the wording of the Abortion Act and grounds “F” and “G”. Which of the following statements are true?

1	“F” & “G” are grounds for TOP in an emergency with only one doctor needing to sign the legal form necessary for the TOP to take place
2	“F” & “G” are grounds for TOP after 24 weeks.
3	“F” relates to TOP to save the woman’s life
4	“F” relates to TOP to prevent grave permanent injury her physical or mental health
5	“F” & “G” do not exist.

Scenario 23. In relation to terms such as “substantial risk”, “grave permanent injury” and “seriously handicapped”, which of the following is true?

A	The terms were defined by a Parliamentary sub-committee, examples were given and are included in Appendix 2 (b) to the Act.
B	The terms were defined by a Parliamentary sub-committee, examples were given and are included in Appendix 2 (c) to the Act.
C	The terms were defined by the General Medical Council, examples were given and the information can be downloaded from the GMC website.
D	The terms were defined by the RCOG, examples were given and the information can be downloaded from the RCOG website.
E	The terms have not been defined.

Scenario 24. Which of the following statement is true about the most common grounds for TOP?

1	TOP is most commonly done on ground A from Certificate A.
2	TOP is most commonly done on ground B from Certificate A.
3	TOP is most commonly done on ground C from Certificate A.
4	TOP is most commonly done on ground D from Certificate A.
5	TOP is most commonly done on ground E from Certificate A.
6	TOP is most commonly done on ground F from Certificate A.
7	TOP is most commonly done on ground G from Certificate A.
8	TOP is most commonly done on ground H from Certificate A.

Scenario 25. Which of the following statements is true in relation to the upper gestational limit for TOP to be legal in the UK?

1	Termination of pregnancy is legal to 24 weeks
2	Termination of pregnancy is legal after 24 weeks if the mother is at serious risk of death or grave, permanent injury or there is a major risk of the fetus having a serious anomaly.
3	Termination of pregnancy is legal after 24 weeks if the mother’s life is at serious risk or there is a major risk of the fetus having a serious anomaly, but only if approved by the Department of Health’s “Late Termination of Pregnancy Assessment Panel”.
4	Termination of pregnancy is illegal after 24 weeks, but is still done if the mother’s life is at serious risk or there is a major risk of the fetus having a serious anomaly and there is a long-standing agreement that the police and legal authorities will “turn a blind eye”.

Scenario 26. Which of the following statement are true in relation to TOP after 24 weeks?

Statements

1	TOP is illegal after 24 weeks
2	The mother must agree to feticide pre-TOP
3	Feticide must be offered
4	There must be very serious grounds for the TOP
5	Gender-selection TOP is unacceptable

Scenario 27. TOPs done under ground E are those done at any gestation because of fetal abnormality. The anomalies are coded using ICD10. The HSA4 notification form relating to each TOP should have details of the ICD10 code for the fetal anomaly.

Which of the following statements is the most accurate in relation to the percentage of HSA4 forms that contain the required information?

A	0- 24%
B	25- 49%
C	50- 59%
D	60- 69%
E	≥ 70%

Scenario 28. TOPs done under ground E are those done at any gestation because of fetal abnormality. Which, if any, of the following statements are true of TOPs under ground E in 2015?

A	the average age was 34, compared to 21 for the average for all grounds
B	congenital malformations were the grounds in > 80% of cases
C	Down’s syndrome was the most common reason for ground E TOP
D	fetal cardiac anomalies were the most common reason for ground E TOP
E	fetal nervous system anomalies were the most common reason for ground E TOP

Scenario 29. Which form relates to certifying that a woman requesting a TOP can have it done legally?

A	HSA1
B	HSA2
C	HSA3
D	HSA4
E	HSA5

Scenario 30. Which form must the practitioner performing the TOP complete to notify the Department of Health that a TOP has been done?

A	HSA1
B	HSA2
C	HSA3
D	HSA4
E	HSA5

Scenario 31. A doctor signing the form giving the grounds for a TOP must have seen the woman.

Option list

A	True
B	False
C	Sometimes
D	Don’t know & don’t care

Scenario 32. A doctor performing a TOP must be one of the doctors who signed the initial form giving the grounds for the TOP.

Option list. Same as previous question.

Scenario 33. What is the time scale for the return of the form notifying that a TOP has taken place?

A	3 working days
B	5 working days
C	1 week
D	2 weeks
E	1 month

Scenario 34. A woman seeks 1^st. trimester TOP on social grounds which she declines to discuss in detail. Which of the following statements apply?

A	TOP can be done under clause A of Certificate A
B	TOP can be done under clause B of Certificate A
C	TOP can be done under clause C of Certificate A
D	TOP can be done under clause D of Certificate A
E	TOP can be done under clause E of Certificate A
F	TOP can be done under clause F of Certificate A
G	TOP can be done under clause G of Certificate A
F	there is no clause authorising TOP on social grounds

Scenario 35. A woman seeks 1st. trimester TOP. She has pulmonary hypertension and has been advised of the risks of pregnancy by her cardiologist. Which of the following statements apply?

A	TOP can be done under clause A of Certificate A
B	TOP can be done under clause B of Certificate A
C	TOP can be done under clause C of Certificate A
D	TOP can be done under clause D of Certificate A
E	TOP can be done under clause E of Certificate A
F	TOP can be done under clause F of Certificate A
G	TOP can be done under clause G of Certificate A
F	there is no clause authorising TOP on these grounds

Scenario 36. A woman books at 26 weeks. She has an unplanned pregnancy. She has pulmonary hypertension and has been advised of the risks of pregnancy by her cardiologist.

Which of the following statements apply?

A	TOP should be offered under clause A of Certificate A
B	TOP should be offered under clause B of Certificate A
C	TOP should be offered under clause C of Certificate A
D	TOP should be offered under clause D of Certificate A
E	TOP should be offered under clause E of Certificate A
F	TOP should be offered under clause F of Certificate A
G	TOP should be offered under clause G of Certificate A
F	there is no clause authorising TOP on these grounds

Scenario 37. Which, if any,  of the following statements are correct about abortion law in Ireland?

A	abortion was legalised in the Republic of Ireland in 2018
B	abortion was legalised in the Republic of Ireland in 2019
C	abortion was legalised in the Republic of Ireland in 2020
D	abortion remains illegal in the Republic of Ireland
E	abortion was legalised in the Northern Ireland in 2018
F	abortion was legalised in the Northern Ireland in 2019
G	abortion was legalised in the Northern Ireland in 2020
H	abortion remains illegal in Northern Ireland

Scenario 38. Which, if any,  of the following statements are correct in relation to mifepristone and misoprostol?

A	mifepristone must be taken in an approved hospital or clinic
B	mifepristone may be taken at home
C	misoprostol must be taken in an approved hospital or clinic
D	misoprostol may be taken at home
E	none of the above

 

Scenario 57.      The Coombs test.

Answer False/True.

a.  the direct test detects maternal IgM on fetal cells.

b.  is used in the investigation of thrombocytopenia.

c.   is positive in the baby with jaundice due to spherocytosis.

d.  who wrote: “A flea hath smaller fleas that on him prey…..”

e.  what was the rest of the verse?

f.   what connection has this verse with the Coomb’s test?

g.  the indirect Coomb’s test is used to detect antibodies in maternal serum.

h.  the direct test uses anti IgG serum.

 

 

Scenario 58.      Fetal origins of adult disease.

Abbreviations.

ADHD:  attention-deficit, hyperactivity disorder

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

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

predispose to the development of disease in adulthood?

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

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

 predispose to the development of disease in adulthood?

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

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

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

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

influences on the fetus, infant and child.

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

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

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

 

Scenario 59.      Caffeine and pregnancy.

ACOG:        American College of Obstetricians and Gynecologists.

NHS:           UK National Health Service.

WHO:         World Health Organisation

Question 1.   For which, if any, of the following is there reasonable evidence of increased risk?

A	miscarriage
B	neural tube defect
C	hydramnios
D	placental abruption
E	preeclampsia
F	preterm birth
G	postpartum haemorrhage
H	fetal growth restriction
I	fetal death in utero
J	stillbirth
K	alteration to fetal heart rate patterns
L	alteration to uterine contractility
M	neonatal opiate withdrawal syndrome
N	leukaemia in the child
O	obesity in the child
P	none of the above

Question 2.   Match each with their recommended safe limit for caffeine in pregnancy.

		0mg	50mg	100mg	200mg	300mg	500mg
A	ACOG
B	NHS
C	WHO

Question 3.   Which of the following is current RCOG advice?

A	there is no known safe level of intake and women must make their own decision
B	there is no known safe level of intake and women should not consume caffeine
C	women should limit intake to a maximum of 200mg daily
D	women should limit intake to a maximum of 300mg daily
E	the recommended safe level should be reviewed
F	none of the above: there is no current advice

 

Scenario 60.      Kisspeptin.

DYNOP:   dynorphin

KSP:         kisspeptin.

NKB:        neurokinin B

Question 1.        Pick the best statement.

A	is a pheromone released by the salivary glands during passionate embraces which ­ syntocinon secretion and sense of pleasure
B	is a digestive enzyme released by the salivary glands during passionate embrace
C	is a digestive enzyme found in human carnivores but not vegetarians
D	is thought necessary for trophoblastic invasion and low levels have been linked to miscarriage, recurrent miscarriage and ↑ risk of PET
E	is named after “Kiss me quick” chocolate
F	does not exist and this question is a very poor joke by someone who should know better

Question 2.        Which, if any of the following are true.

A	KSP is a KNDy neuropeptide secreted in the hypothalamus
B	KSP stimulates GnRH neurones
C	KSP stimulates FSH production > LH production
D	KSP stimulates FSH production < LH production
E	KSP stimulates FSH production and LH production equally
F	KSP is a key factor in puberty
G	KSP is a key factor in normal reproductive physiology
H	¯ KSP is pathognomonic for Kallmann’s syndrome.
I	dynorphin stimulates GnRH neurones
J	neurokinin B stimulates GnRH neurones

 

Scenario 61.      Marfan syndrome.

AR:              aortic root.

ARD:           aortic root dilatation.

cf:               ‘compare with’, derived from the Latin word for ‘to compare’.

Mas:           Marfan’s syndrome.

TGF-β:        transforming growth factor beta.

Question 1.        Which, if any, of the following statements are true in relation to Marfan syndrome?

A	Mas is a connective tissue disorder
B	Mas is an autoimmune condition
C	Mas is due to defects in fibrillin-1
D	Mas is due to mutation of the FUN1 gene
E	only one variant of the gene causes Mas
F	the unique variant of the gene that causes Mas explains the uniform phenotype
G	inheritance is autosomal dominant
H	inheritance is autosomal recessive
I	inheritance is X-linked recessive

Question 2.        Which, if any, of the following is the incidence of Mas?

A	~ 1 in 500
B	~ 1 in 5,000
C	~ 1 in 50,000
D	~ 1 in 500,000

Question 3.        What % of cases arise from new mutations?

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

Question 4.        How many mutations of the Marfan gene have been identified?

A	< 100
B	101-200
C	201-300
D	301-400
E	401-500
F	>500
G	>1,000
H	>2,000

Question 5.        Which of the following are features of classical Mas?

A	arachnodactyly
B	brachydactyly
C	cauda equina syndrome
D	ectopia lentil
E	frequenting of lax joints
F	kyphosis
G	long long bones
H	scoliosis
I	tall stature

Question 6.        Which, if any, of the following are features of the classical Mas?

A	aortic coarctation
B	aortic dissection
C	aortic regurgitation
D	aortic root dilatation
E	aortic stenosis
F	mitral regurgitation
G	mitral stenosis
H	pulmonary hypertension
I	tricuspid regurgitation
J	tricuspid stenosis

Question 7.        Which, if any, of the following are features of the classical Mas?

A	cataract
B	chronic obstructive airways disease
C	glaucoma
D	myopia
E	pulmonary bullous changes
F	pulmonary fibrosis
G	recurrent pneumothorax
H	stretch marks
I	striae distensae
J	melanoma

Question 8.        Which, if any, of the following are features of the classical Mas?

A	cauda equina syndrome
B	dural ecstasy
C	dural ectasia
D	dural ectoplasm
E	hydrocephalus

Question 9.        Approximately what percentage of those with Mas have cardiac involvement?

A	< 30
B	40
C	50
D	60
E	70
F	80
G	≥ 90

Question 10.    What is the generally accepted cut-off for aortic replacement in the non-pregnant?

A	AR > 3 cm.
B	AR > 4 cm.
C	AR > 5 cm.
D	AR > 7.5 cm.
E	AR > 10 cm.
F	none of the above

Question 11.    What is the generally accepted cut-off for high risk associated with pregnancy?

A	AR > 3 cm.
B	AR > 4 cm.
C	AR > 5 cm.
D	AR > 7.5 cm.
E	AR > 10 cm.
F	none of the above

Question 12.    Which, if any, of the following statements are true in relation to the maternal risks

associated with an AR greater than the high-risk cut-off?

A	worsening aortic dilatation
B	aortic dissection more likely
C	aortic stenosis
D	cervical incompetence more likely
E	ectropion lentis more common
F	gestational hypertension more common
G	HELLP syndrome more common
H	hydramnios more common
I	pulmonary embolism more common

Question 13.    Which, if any, of the following statements are true in relation to the fetal risks

associated with maternal Mas?

A	↑ risk of breech presentation at term
B	↑ risk of neural tube defect
C	↑ risk of perinatal mortality
D	↑ risk of preterm birth
E	25% risk of Mas
F	none of the above

TOG CPD. 2007. 19. 1. These are open access, so are reproduced here.

Pregnancy is associated with

1.     increased pulmonary blood flow.                                                                   True / False

2.     decreased stroke volume.                                                                                True / False

 3.    increased heart rate.                                                                                         True / False

Indication for elective caesarean section includes

4.     aortopathy with aortic root > 4 cm.                                                               True / False

5.     aortic dissection or aneurysm.                                                                        True / False

In women with congenital heart disease predictors for adverse neonatal events include

6.     prior maternal cardiac event.                                                                          True / False

7.     presence of left-to-right shunts.                                                                     True / False

Regarding Marfan syndrome and pregnancy,

8.     the risk of aortic dissection or rupture is reduced.                                      True / False

9.     overall maternal mortality is about 1 in 4.                                                    True / False

10.   aortic root diameter should be monitored throughout pregnancy.         True / False

The offspring of a mother with congenital heart disease

11.   are at increased risk of inheriting congenital heart disease.                                   True / False

12.   are at increased risk of complications during the neonatal period.         True / False

Tetralogy of Fallot is

13.   the most common form of cyanotic heart disease.                                     True / False

14.   often associated with pulmonary regurgitation.                                         True / False

In women with congenital heart disease

15.   ventouse delivery under epidural anaesthesia is generally recommended.       True / False

16.   cardiac arrhythmia is one of the main primary cardiac events in pregnancy. True / False

In pregnant women with coarctation of the aorta,

17.   blood pressure must be carefully controlled to avoid low birthweight.       True / False

In women with transposition of the great arteries

18.   even if this has been repaired, arrhythmia can occur in pregnancy.       True / False

In women with cyanotic heart disease without pulmonary hypertension

19    up to 1 in 2 pregnancies end in premature delivery.                                   True / False

In women with pulmonary vascular disease

20    about a third of pregnancies will result in intrauterine growth restriction.               True / False