18
August 2025. Role-players: 1.
Role-players:
2.
|
19 |
Role-play 1. Topic emailed just before tutorial |
|
20 |
Role-play 2. Ditto |
|
21 |
EMQ. Montgomery & consent |
|
22 |
EMQ. Gestational Trophoblastic Disease (GTD) |
19.
Role-play
1. Candidate’s
instructions will be e-mailed shortly before the tutorial.
20.
Role-play
1. Candidate’s
instructions will be e-mailed shortly before the tutorial.
21.
Montgomery Ruling.
Abbreviations.
BMA: British
Medical Association.
GMC: General
Medical Council.
Question
1.
Which, if any, of the following statements is most accurate?
|
A |
The
Montgomery ruling largely replaces the Bolam ruling |
|
B |
The Montgomery ruling largely replaces the Chester
ruling |
|
C |
The Montgomery ruling largely replaces the Sidaway
ruling |
|
D |
The Montgomery ruling is being contested in the
European Court by the GMC as it infringes the rights of doctors |
|
E |
The Montgomery ruling is being contested in the
European Court by the BMA as it infringes the rights of doctors |
Question
2.
Which, if any, of the following statements are true?
|
A |
the
level of risk, however small, must be disclosed if a patient requests it |
|
B |
the level of risk of damage from a procedure need not
be disclosed if < 1% |
|
C |
the level of risk of damage from a procedure need not
be disclosed if < 10% |
|
D |
a material risk is one that would be reflected in
damages > £100,000 if negligence were proved in court |
|
E |
a material risk is one that would be reflected in
damages > £1,000,000 if negligence were proved in court |
|
F |
a material risk is one that involves anatomical damage,
not emotional or psychological |
|
G |
a material risk is one that a reasonable person in the
patient’s situation would be likely to regards as significant |
22.
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 |
|
A |
definite
diagnosis is usually made by ultrasound |
|
B |
definitive
diagnosis requires a +ve test for P57KIP2 |
|
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 |
|
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 p57KIP2?
|
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
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
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