EMQ set 1

Options for questions 1-2

A)    Cerazette (desogestrel) progestogen-only pill

B)     Noriday (norethisterone) progestogen-only pill
Norgeston (Levonorgestrel) Progestogen-only pill

C)    Combined oral contraceptive pill

D)    Depo-medroxyprogesterone acetate

E)     Depo- Norethisterone oenanthate

F)     Copper IUCD

G)    Etonorgestrel implant

H)    Levonorgestrel IUS

I)       All options may be used

J)       No option is suitable

For each scenario described below, choose the contraceptive option that may safely be used (UKMEC category 1 or 2) from the above list of options. Each option may be used once, more than once, or not at all.

1)      A 33 year old woman has been referred for contraceptive advice. She has been diagnosed with SLE and has positive anti-phospholipid antibodies. Her BMI is 23 kg/m2 and she has never smoked. Her LMP was 1 week earlier with a regular 28 day cycle. FBC and renal function tests are normal.

2)      A 28 year old woman has been referred for contraceptive advice. She has been diagnosed with SLE and has positive anti-phospholipid antibodies. Her BMI is 23 kg/m2 and she has never smoked. Her LMP was 1 week earlier with a regular 28 day cycle. She has severe thrombocytopaenia but renal function tests are normal.

Options for question 3-4

A)    External beam radiotherapy

B)     Chemotherapy

C)    Combined chemo-radiotherapy

D)    No additional treatment

E)     Laparoscopic pelvic lymphadenectomy

F)     Laparotomy + pelvic lymphadenectomy

G)    Laparoscopy + bilateral salpingo-oophrectomy

H)    Bilateral salpingo-oophrectomy + omentectomy

I)       Intracavitary radiotherapy

J)       Intracavitary + external beam radiotherapy

K)    HPV vaccination

For each scenario described below, choose the single most appropriate management from the above list of options. Each option may be used once, more than once, or not at all.

3) A healthy 67 year old woman has a vaginal hysterectomy because of prolapse symptoms. Histological examination of the specimen identifies a 3 x 7mm area of squamous cell carcinoma in-situ.

4) A 38 year old woman with dysfunctional uterine bleeding has a laparoscopic total hysterectomy with conservation of the ovaries. Histological examination identifies a squamous cell carcinoma of the cervix measuring 2.5 x 4mm with a depth of invasion of 1.5mm.

Options for question 5

A)       Inter-pregnancy interval of 5 years

B)      BMI of 37 kg/m2

C)      BMI of 45 kg/m2

D)      3 previous first trimester miscarriages

E)      History of thyroid disease

F)       Pre-eclampsia in her mother and sister

G)      Di-chorionic di-amniotic twin pregnancy

H)      Known carrier of Factor V Leiden mutation

I)         History of recurrent miscarriage and carrier of Factor V Leiden mutation

J)       Placental abruption in a previous pregnancy

K)      Unexplained intra-uterine death in a previous pregnancy

L)       Maternal age 29 years with chronic hypertension well controlled with beta-blockers

For each scenario described below, choose the single most appropriate option from the above list of options. Each option may be used once, more than once, or not at all.

5) A woman has been referred to the antenatal clinic at 10 weeks gestation. Low dose aspirin (75 mg once daily) should be recommended in the following circumstances

Options for question 6-7

A)    Maintain BP below 140/90 mmHg

B)     Maintain systolic BP below 160 mmHg

C)    Maintain diastolic BP below 80 mmHg

D)    BP less than 150/100 mmHg

E)     BP less than 150/100 mmHg with diastolic BP not below 80 mmHg

F)     Maintain mean arterial pressure below 125 mmHg

G)    Maintain mean arterial pressure below 110 mmHg

H)    Maintain BP below 120/80 mmHg

I)       Maintain BP below 160/110 mmHg

J)       Maintain diastolic BP between 80-90 mmHg

K)    Maintain systolic BP between 140-160 mmHg

For each scenario described below, choose the single most appropriate target range for blood pressure control from the above list of options. Each option may be used once, more than once, or not at all.

6) A 40 year old woman attends the antenatal clinic at 20 weeks gestation. She has a history of chronic hypertension and ACE-inhibitors were changed to labetalol prior to pregnancy. Her renal function is normal and her BP is 162/102 mmHg with no proteinuria.

7) A 32 year old woman attends the antenatal clinic at 20 weeks gestation. She has a history of chronic hypertension secondary to reflux nephropathy and is known to have mild renal impairment. Her BP is 160/100 mmHg with no proteinuria.

Options for questions 8

A)    The baby cannot be registered with indeterminate sex

B)     The funeral may take place before registration of stillbirth

C)    Registration of stillbirth is not necessary

D)    The midwife should examine the baby and decide the sex

E)     The obstetrician should examine the baby and decide the sex

F)     The perinatal pathologist should examine the baby and decide the sex

G)    The sex should be determined using QF-PCR

H)    The sex should be determined using FISH

I)       The sex can be registered as indeterminate and later changed

J)       The sex of the baby is not required for registration

K)    The sex should be determined at post-mortem

For each scenario described below, choose the single most appropriate option from the above list of options. Each option may be used once, more than once, or not at all.

8) A 36 year old woman presents with intra-uterine fetal death at 26 weeks gestation. Following induction of labour, she gives birth at 12:30 and the baby is severely macerated. For cultural reasons, the funeral has to take place by 18:00. The parents therefore wish to know the baby’s sex and have given consent for fetal karyotype but not for a post-mortem.

Options for question 9

A)    FBC, renal function tests, group & save

B)     FBC, renal function tests, liver function tests, coagulation screen

C)    FBC, renal function tests, liver function tests, Kleihauer test

D)    FBC, renal function tests, glucose tolerance test, Kleihauer test

E)     FBC, renal function tests, CRP, Kleihauer test

F)     FBC, renal function tests, coagulation screen, Kleihauer test

G)    FBC, renal function tests, thrombophilia screen, glucose tolerance test, Kleihauer test

H)    FBC, renal function tests, thrombophilia screen, glucose tolerance test

I)       FBC, renal function tests, liver function tests, thrombophilia screen

J)       FBC, renal function tests, thrombophilia screen, group & save

K)    FBC, renal function tests, maternal and paternal karyotype

For each scenario described below, choose the single most appropriate group of investigations that should be performed prior to delivery from the above list of options. Each option may be used once, more than once, or not at all.

9) A healthy 23 year old woman presents at 35 weeks gestation with a history of reduced fetal movements for 24 hours. Intra-uterine fetal death is diagnosed on ultrasound scan. She is Rhesus negative. Her BP is 120/90 mmHg and there is no proteinuria.

1. D
2. B
3. E
4. D
5. F
6. A
7. A
8. I
9. F

1. f

2 .j

3. a

4. j

5. i

6. d

7. a

8.i

9.f

1-I  2 H    3 E    4  D   5 L  6 A  7 A   8 I   9  A

1. F

2. H

3. D

4. G

5. I

6. E

7. E

8. I

9. F

1.F  2.H  3.G  4.H  5.L  6.E  7.A  8.I  9.F

1. f        2.h    3.g   4d  5.d      6.d     7.e   8.i      9.d

1.F  2.J  3.D  4.E  5.L  6.E  7.A  8.I   9.F

1.F  2. H.  3.D  4.E  5.L  6.E  7.A  8.I  9.F

1. F

2. B

3. D

4. F

5.A

6.A

7.A

8.B

9.C

1.f  2.j 3.d 4.d 5.i 6.e 7.e 8.e 9.f 

1 F    2H   3E   4D   5L    6E   7A   8I   9C

1-f ; 2-d  ; 3-g ;4-e ;5-d ;6 -f; 7-e ; 8-i ;9-f

1 F

2 J

3 D

4 D

5 L

6 E

7 E

8 E

9 B

1.f, 2.i, 3.d, 4.e, 5.l, 6.d, 7.e, 8.i, 9. f

1- I

2- I

3- D

4- D

5- L

6- E

7- A

8- H

9- C

1.f  2.J 3.D 4.E 5.L 6.E 7.A 8.G.9.F

1.f  2.J 3.D 4.E 5.L 6.E 7.A 8.G.9.F

1  f

2   c

3   d

4   d

5   d

6   a

7   a

8   i

9   f

1. I

2.H

3.D

4.G

5.D

6.F

7.E

8.B

9.G

1= F

2= H

3= G

4= D

5= L

6= E

7= J

8= F

9= F

1-I

2-h

3-d

4-d

5-l

6-e

7-a

8-h

9-g

1-a, 2-a, 3-d, 4-d, 5-i, 6-e, 7-e, 8-e, 9-c

1-F

2-J

3-D

4-D

5-L

6-E

7-A

8-I

9-F

1    I

2     

3    D

4    E

5   F

6    A

7    F

8    I

9    F 

1: F

2; H

3; D

4: D

5:L

6: E

7: E

8:E

9: F

j reply

1.F

2.J

3.D

4.D

5.L

6.E

7.A

8.G

9.G

1.F

2.J

3.E

4.J

5.I

6.A

7.E

8.I

9.F

1-G ,2-G, 3-D, 4-D, 5-C, 6-D, 7-A ,8-I, 9-C, 

1 F

2 F

3 D

4 D

5 I

6 F

7 E

8 B

9 A

1) f 2) j 3) g 4) g 5) f  6) d 7) e 8) b 9) F

Dear Paul,can we get answer please

1 f     2 h  3 d  4 e  5 i  6 e  7 d  8 i  9 f

1F  2J 3D  4D  5L  6E  7A  8I  9F

1: F. Copper coil can be inserted any time in the cycle, and is not contraindicated in SLE with positive antibodies unlike the other forms listed.

2: J. No option is suitable as she has positive antibodies and severe thrombocytopaenia, and this the copper coil is also contraindicated. 

3: D. This is Stage 0 and therefore cone biospy or hysterectomy is treatment of choice.

4: D. Invasion depth <3mm and width <7mm suggests stage Ia1. Simple hysterectomy is the treatment of choice - already done. 

5: L. New NICE guidelines say that chronic hypertension, whether or not treated, is high risk for for developing preclampsia, and 75mg aspirin can reduce risk of developing by 10%

6: D. Uncomplicated chronic hypertension should be kept <150/100 so as not to reduce placental blood flow in a compensated system.

7: A. Mild renal impairment = end organ damage and so BP should be kept <140/90

8: B. Stillbirths in England and Wales must normally be registered within 42 days of the stillbirth but cannot be registered more than 3 months after its occurrence.

9: G. FBC and renal function is common to all answers. Thrombophilia screen is recommended for all IUD, Kleihauer is necessary given Rhesus status. Thus G is the only combination to contain all these. GTT is recommended in some unit protocols.

1) F
2) J

• SLE with positive or unknown anti-phospholipid antibodies is UKMEC 4 for COCP and UKMEC 3 for all progestogen-only contraceptives.
• SLE with severe thrombocytopaenia is UKMEC 3 for copper IUCD

3) D
4) D

Stage 0 Cervical Cancer 

• Hysterectomy is appropriate for women who have completed their family therefore no additional treatment needed

Stage Ia Squamous cell carcinoma
 

• Ia: Invasive carcinoma which can be diagnosed on microscopy only with deepest invasion ≤ 5mm and largest extension ≥ 7mm
• Treatment options:
• Total hysterectomy
• If depth of invasion < 3 mm (Stage Ia1) and no lympho-vascular invasion, the frequency of lymph node involvement is sufficiently low that lymph node dissection is not required. Additional treatment is therefore not necessary.

5) L

Risk factors for pre-eclampsia: High risk

• Hypertensive disease in a previous pregnancy
• Chronic hypertension
• Chronic renal disease
• Autoimmune disease (SLE or antiphospholipid syndrome)
• Diabetes mellitus

Recommended intervention: Aspirin 75 mg daily from 12 weeks until delivery. Risk of pre-eclampsia reduced by 10% with a 10% reduction in risk of pre-term birth.

Risk factors for pre-eclampsia: Moderate risk

• First pregnancy
• Age ≥40 years
• Inter-pregnancy interval > 10 years
• BMI ≥ 35 kg/m² at booking
• Family history of pre-eclampsia
• Multiple pregnancy

Recommended intervention: If ≥ 2 moderate risk factors, Aspirin 75 mg of daily from 12 weeks until delivery.

6) E
7) A

• Antihypertensive treatment significantly reduces the risk of severe hypertension.
• There is an increased risk of severe hypertension with less tight control of blood pressure compared to tight control, but no other differences in maternal or perinatal outcomes.
• The more blood pressure was reduced in women taking antihypertensives, the more the birthweight of their babies was reduced (every 10 mmHg fall in mean arterial pressure resulting in 145 g decrease in birthweight). Treatment should therefore aim to lower blood pressure from the moderate or severe range while avoiding excessive reductions that may affect fetal growth.
• Women with evidence of target-organ damage from hypertension will need a lower target blood pressure than women without such changes
• In women with uncomplicated chronic hypertension BP should be maintained at < 150/100 mmHg and diastolic BP should not be lowered below 80 mmHg.
• In women with target-organ damage secondary to chronic hypertension (e.g. kidney disease) treatment should aim to maintain BP < 140/90 mmHg. 

8) I

Determination of sex

• May be difficult in the very pre-term or severely macerated or hydropic baby. Options include
• Examination of external genitalia by two experienced clinicians
• Rapid karyotype using FISH or QF-PCR – results within 2 working days
• Post-mortem examination
• Sex may be based on earlier ultrasound scan
• Parents may examine genitalia and determine sex for themselves
• Parents may choose not to sex the baby
• Baby can be registered as having indeterminate sex

Registration of stillbirth

• The doctor or midwife attending the stillbirth should issue a Medical Certificate of Stillbirth to enable the birth to be registered.
• The mother (or father if married) is responsible for registering the stillbirth within 42 days (21 in Scotland)
• The responsibility for registration can be delegated to a health professional.
• The sex of the baby can be registered as indeterminate and later changed
• The parents are then issued with a Certificate of Stillbirth and the documentation for burial or cremation. A certificate for cremation cannot be issued before the registration.

9) F

Investigations
Maternal - routine

• FBC, U&E, LFT, bile salts (Pre-eclampsia, sepsis / haemorrhage, cholestasis)
• PT, APTT, Fibrinogen (DIC – occurs in up to 10% within 4 weeks of late IUFD, rising to 30% thereafter). Repeat twice a week if the woman wishes expectant management.
• Kleihauer test (feto-maternal haemorrhage [all women, not just Rh –ve] and determine dose of anti-D). Rh –ve women should have an urgent Kleihauer test to detect large feto–maternal haemorrhage that might have occurred earlier.
• Anti-D should be administered as soon as possible.
• For large feto-maternal haemorrhage, the Kleihauer test should be repeated at 48 hours to ensure the fetal red cells have cleared. Persistently positive Kleihauer test may be due to a Rh –ve fetus or very large haemorrhage. Fetal blood group may therefore be essential.
• Random blood glucose and HbA1c (Screening for diabetes mellitus). In women with gestational diabetes, glucose tolerance normalises within hours of fetal death
• Maternal serology (infection with parvovirus, CMV, herpes, Toxoplasma, rubella)
• Thrombophilia screen. Repeat tests after at least 6 weeks if abnormal
   

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