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Question 1
Incorrect
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Which of the following statements regarding hormone replacement therapy in postmenopausal women at the age of 55 is incorrect?
Your Answer: In women who are more than 3 years post menopause, raloxifene is effective in reducing vertebral fracture risk
Correct Answer: Combination with Alendronate is usually encouraged
Explanation:Taking hormone replacement therapy for more than 5 years can increase the risk of developing breast cancer. HRT is not recommended as treatment for osteoporosis alone in postmenopausal women older than 60. Raloxifene reduces risk of vertebral fracture in post menopausal women.
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This question is part of the following fields:
- Gynaecology
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Question 2
Correct
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Your consultant agrees to supervise you performing a Caesarean Section (CS). When making a Joel Cohen incision where should this be placed?
Your Answer: 3 cm above the symphysis pubis
Explanation:The Joel Cohen incision is superior to the Pffannenstiel incision. It is a straight incision that is 3 cm below the line joining the anterior iliac spines.
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This question is part of the following fields:
- Clinical Management
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Question 3
Correct
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Which cell type of the testis secrete inhibin?
Your Answer: Sertoli cells
Explanation:Summary points of the two key testicular cell types:
1. Sertoli Cells = Secrete Inhibin. Forms blood-testis barrier. Have FSH receptors
2. Leydig Cells = Secrete testosterone. Have LH receptors -
This question is part of the following fields:
- Anatomy
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Question 4
Correct
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The major cause of the increased risk of morbidity & mortality among twin gestation is:
Your Answer: Preterm delivery
Explanation:Twin pregnancy is associated with a number of obstetric complications, some of them with serious perinatal consequences, especially for the second twin. The rate of perinatal mortality can be up to six times higher in twin compared to singleton pregnancies, largely due to higher rates of preterm delivery and fetal growth restriction seen in twin pregnancies. Preterm birth and birth weight are also significant determinants of morbidity and mortality into infancy and childhood. More than 50% of twins and almost all triplets are born before 37 weeks of gestation and about 15–20% of admissions to neonatal units are associated with preterm twins and triplets.
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This question is part of the following fields:
- Obstetrics
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Question 5
Correct
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A 23-year-old woman with diffuse pelvic pain and vaginal bleeding presents to the emergency room. She claims that it is around the time that she usually has her period. She has previously experienced defecation discomfort, dyspareunia, and dysmenorrhea. The patient claims that she has previously experienced similar symptoms, but that the agony has suddenly become unbearable. Her abdomen is soft, with normal bowel sounds and no rebound soreness, according to her physical examination. There is no costovertebral discomfort and the patient does not guard. Blood in the posterior vaginal vault, a closed os, and no palpable masses or cervical motion pain are all findings on her pelvic examination. What is the most likely diagnosis?
Your Answer: Endometriosis
Explanation:Endometriosis is defined as the presence of normal endometrial mucosa (glands and stroma) abnormally implanted in locations other than the uterine cavity. Approximately 30-40% of women with endometriosis will be sub fertile. About one third of women with endometriosis remain asymptomatic. When they do occur, symptoms, such as the following, typically reflect the area of involvement:
– Dysmenorrhea
– Heavy or irregular bleeding
– Pelvic pain
– Lower abdominal or back pain
– Dyspareunia
– Dyschezia (pain on defecation) – Often with cycles of diarrhoea and constipation
– Bloating, nausea, and vomiting
– Inguinal pain
– Pain on micturition and/or urinary frequency
– Pain during exercisePregnancy, appendicitis, ureteral colic and ruptured ectopic pregnancy all do not present with dysmenorrhea, pain on defecation and dyspareunia. Presence of a non tender, soft abdomen also rules out these conditions.
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This question is part of the following fields:
- Gynaecology
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Question 6
Correct
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Gonadotropin-releasing hormone (GnRH) stimulates the release of:
Your Answer: Luteinizing hormone
Explanation:Gonadotropin-releasing hormone (GnRH) is the hormone responsible for the release of follicle-stimulating hormone (FSH) and luteinizing hormone (LH) from the anterior pituitary gland.
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This question is part of the following fields:
- Endocrinology
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Question 7
Correct
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All of the following factors are associated with an unstable lie of the foetus except?
Your Answer: Cervical fibroids
Explanation:Unstable lie means that the foetus is still changing its position even at 36 weeks of gestation. A number of factors are responsible for this positioning such as multi gravida, placenta previa, prematurity and fibroids present in the fundus. Cervical fibroids have little association with unstable lie of the foetus.
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This question is part of the following fields:
- Obstetrics
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Question 8
Incorrect
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A 36 year old patient is seen in clinic for follow up of a vaginal biopsy which confirms cancer. What is the most common type?
Your Answer: Adenocarcinoma
Correct Answer: Squamous cell carcinoma
Explanation:Squamous cell carcinoma is the most common type of vaginal cancer.
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This question is part of the following fields:
- Clinical Management
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Question 9
Correct
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You are asked to see a 26 year old patient following her first visit to antenatal clinic. She is 9 weeks pregnant and bloods have shown her to be non-immune to Rubella. She is concerned about congenital rubella syndrome (CRS). What is the most appropriate advice to give?
Your Answer: Advise vaccination after birth regardless of breast feeding status
Explanation:Congenital rubella infection that occurs after 16 weeks gestation does not typically cause fetal abnormalities. This however plays no part in vaccination advice. Rubella vaccine is live and should not be given during pregnancy. The mother should be offered vaccination after giving birth. It is safe for the vaccine (typically given as combined MMR) to be administered if the mother is breastfeeding.
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This question is part of the following fields:
- Microbiology
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Question 10
Correct
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A 23 year old patient presents to the emergency department with sudden onset of severe lower abdominal and pelvic pain. History reveals she normally has regular 28 day cycles but she missed her last period. Past medical history reveals 2 termination of pregnancy procedures in the past 3 years. The most recent one 6 months ago. She smokes 5 cigarettes per day.
Your Answer: Ectopic pregnancy
Explanation:This patient is most likely to have a ruptured ectopic pregnancy. The history of multiple TOPs suggests her contraceptive methods are not reliable and her missed period is suggestive she may currently be pregnant. There is no temperature or vaginal discharge to suggest PID though this is of course possible as is appendicitis. The last termination was 6 months ago so endometritis is unlikely.
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This question is part of the following fields:
- Clinical Management
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Question 11
Incorrect
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Lactogenesis at term is stimulated by which hormone?
Your Answer: Dopamine
Correct Answer: Prolactin
Explanation:Prolactin is the hormone that is responsible for the production of milk (Lactogenesis). Oxytocin is responsible for the let down reflex during suckling.
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This question is part of the following fields:
- Clinical Management
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Question 12
Correct
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Which of the following statements regarding Management of Beta Thalassaemia in Pregnancy is not part of the RCOG guidelines?
Your Answer: Folic acid 5 mg daily should be commenced 12 months prior to conception
Explanation:Women with Beta-Thalassaemia require significant extra input during pregnancy. Folic acid 5 mg daily should be commenced 3 months prior to conception in these patients. NOTE Women with thalassaemia who have undergone splenectomy OR have a platelet count >600 should continue or be commenced on Aspirin (75 mg/day)
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This question is part of the following fields:
- Genetics
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Question 13
Incorrect
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A 18-year-old girl arrives at the ER with severe abdominal pain. When it started, she was in the school band. She says the pain began 30 minutes ago in the left lower region and didn't radiate. On a scale of 1 to 10, the discomfort is a 7 and is not accompanied by nausea, vomiting, or diarrhoea. Menarche began at the age of thirteen. Her menses were erratic at first, but she has had regular periods for the past six months. Her vital signs are stable, and she has no fever. She uses combination oral contraceptives and is sexually active. She denies taking any other drugs. A flat abdomen with regular peristalsis is revealed on physical examination. Pelvic examination indicates a regular vagina with a normal-appearing cervix. There is no mucopurulent cervical discharge. Bimanual examination is remarkable with a tender 5-cm mass in the left adnexa. A pregnancy test result is negative. A pelvic sonogram exhibits a normal intrauterine pregnancy and a 5 X 6 cm complex mass of the left ovary, with focal areas of calcification. Which of the following is the most likely diagnosis?
Your Answer: Follicular cyst
Correct Answer: Cystic teratoma
Explanation:Mature cystic teratomas of the ovary are often discovered as incidental findings on physical examination, during radiographic studies, or during abdominal surgery performed for other indications.
Most mature cystic teratomas can be diagnosed at ultrasonography (US) but may have a variety of appearances, characterized by echogenic sebaceous material and calcification.
Follicular cysts are simple fluid-filled cysts and never have calcifications.
Mucinous cystadenoma usually develop in the third to fifth decades of life and typically cause vague symptoms, such as increasing abdominal girth, abdominal or pelvic pain, emesis, fatigue, indigestion, constipation, and urinary incontinence However, calcifications are not usually seen.
Brenner tumour is also a benign epithelial ovarian tumour but it is solid, occurring most often in women over 50 years of age.
Serous cystadenoma also does not show calcifications.
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This question is part of the following fields:
- Gynaecology
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Question 14
Correct
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You see a 28 year old woman who is 22 weeks pregnant. She complains of vaginal soreness and yellow frothy discharge. Microscopy confirms Trichomoniasis. What percentage of infected pregnant women present with yellow frothy discharge?
Your Answer: 20%
Explanation:Trichomoniasis is considered a sexually transmitted infection found both in men and women, and is caused by the flagellate protozoan Trichomonas vaginalis. The organism is mainly found in the vagina and the urethra. Though many infected women can be asymptomatic, they can also present with yellow frothy vaginal discharge, itching and vaginitis, dysuria or an offensive odour. About 20-30% of women with the infection however are asymptomatic. For the diagnosis of t. vaginalis in women, a swab is taken from the posterior fornix during speculum examination and the flagellates are detected under light-field microscopy. The recommended treatment for t. vaginalis during pregnancy and breastfeeding is 400-500mg of metronidazole twice daily for 5 -7 days. High dose metronidazole as a 2g single dose tablet is not advised during pregnancy. All sexual partners should also be treated and screened for other STIs.
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This question is part of the following fields:
- Clinical Management
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Question 15
Incorrect
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Which of the following muscles is NOT a constituent of the pelvic floor (diaphragm)?
Your Answer: Iliococcygeal
Correct Answer: Piriformis
Explanation:The pelvic floor or diaphragm is composed of Coccygeus and Levator Ani. Levitator Ani is composed of 3 muscles: puborectalis, pubococcygeus and iliococcygeal. Although Piriformis assists in closing the posterior pelvic outlet it is not considered a component of the pelvic floor
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This question is part of the following fields:
- Anatomy
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Question 16
Correct
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After birth, all of the following vessels constrict, EXCEPT the:
Your Answer: Hepatic portal vein
Explanation:Immediately after birth the liver is deprived of the large flow of blood supplied during foetal development via the umbilical vein and portal sinus. Simultaneously the blood pressure in the portal sinus, previously as high as in the umbilical vein, falls.
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This question is part of the following fields:
- Physiology
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Question 17
Correct
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The β-hCG curve in maternal serum in a normal pregnancy peaks at:
Your Answer: 10 weeks of pregnancy
Explanation:During the first 8 weeks of pregnancy, concentrations of hCG in the blood and urine usually double every 24 hours. Levels of the hormone typically peak at around 10 weeks, decline until 16 weeks, then remain constant.
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This question is part of the following fields:
- Physiology
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Question 18
Incorrect
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A 35-year-old lady complained of pelvic pain for three months. A tumour in her right iliac fossa was discovered during an examination. An ovarian cyst measuring 8 cm x 12 cm is visible on ultrasonography. What is the next management step?
Your Answer: Reassurance
Correct Answer: Refer to a gynaecologist
Explanation:Many patients with simple ovarian cysts based on ultrasonographic findings do not require treatment.
In a postmenopausal patient, a persistent simple cyst smaller than 10cm in dimension in the presence of a normal CA125 value may be monitored with serial ultrasonographic examinations.Premenopausal women with asymptomatic simple cysts smaller than 8cm on sonograms in whom the CA125 value is within the reference range may be monitored, with a repeat ultrasonographic examination in 8-12 weeks.
Persistent simple ovarian cysts larger than 5-10 cm, especially if symptomatic, and complex ovarian cysts should be considered for surgical removal.
For this patient, a premenopausal woman, with an ovarian cyst size 8 cm x 12cm. Surgical management is indicated, hence referral to gynaecologist is appropriate.
Laparotomy or laparoscopic excision of cyst should be considered and performed by the gynaecologist not general practitioner.
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This question is part of the following fields:
- Gynaecology
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Question 19
Correct
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A chronic alcoholic lady presented to the medical clinic with complaints of an increase in abdominal size. Ultrasound was performed and revealed a foetus in which parameters correspond to 32 weeks of gestation. Upon history taking, it was noted that she works in a pub and occasionally takes marijuana, cocaine, amphetamine and opioid. Which of the following is considered to have the most teratogenic effect to the foetus?
Your Answer: Alcohol
Explanation:All of the conditions that comprise fetal alcohol spectrum disorders stem from one common cause, which is prenatal exposure to alcohol. Alcohol is extremely teratogenic to a foetus. Its effects are wide-ranging and irreversible. Although higher amounts of prenatal alcohol exposure have been linked to increased incidence and severity of fetal alcohol spectrum disorders, there are no studies that demonstrate a safe amount of alcohol that can be consumed during pregnancy. There is also no safe time during pregnancy in which alcohol can be consumed without risk to the foetus. Alcohol is teratogenic during all three trimesters. In summary, any amount of alcohol consumed at any point during pregnancy has the potential cause of irreversible damage that can lead to a fetal alcohol spectrum disorder.
In general, diagnoses within fetal alcohol spectrum disorders have one or more of the following features: abnormal facies, central nervous system abnormalities, and growth retardation.
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This question is part of the following fields:
- Obstetrics
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Question 20
Correct
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In reducing the risk of blood transfusion in pregnancy and labour which of the following strategies is recommended?
Your Answer: A Hb of less than 10.5g/l should prompt haematinics and exclusion of haemoglobinopathies
Explanation:Anaemia in pregnancy is most frequently caused by iron or folate deficiency, however, a wide variety of other causes may be considered, especially if the haemoglobin value is below 9.0 g/dL. A haemoglobin level of 11 g/dL or more is considered normal early in pregnancy, with the upper limit of the ‘normal range’ dropping to 10.5 g/dL by 28 weeks gestation. Haemoglobin < 10.5 g/dl in the antenatal period, one should exclude haemoglobinopathies and consider haematinic deficiency. Oral iron is 1st line treatment for iron deficiency. Anaemia not due to haematinic deficiency will not respond to any form of iron. This should be managed with transfusion
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This question is part of the following fields:
- Clinical Management
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Question 21
Correct
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A 21-year-old woman at 39 weeks of gestation in her second pregnancy is admitted in the hospital for severe abdominal pain. She notes that also has been having vaginal bleeding of about one litre and uterine contractions are present. Her previous pregnancy was a vaginal, without any complications. Her current blood pressure is 95/50 mmHg with a pulse rate of 120 beats/min. On physical examination, the uterus is palpable at the level of the xiphisternum and is firm. It is acutely tender to palpation. Fetal heart sounds cannot be heard on auscultation or with Doppler assessment. The cervix is 4 cm dilated and fully effaced. Immediate resuscitative measures are taken. Which of the following is the most appropriate next step in management for this patient?
Your Answer: Amniotomy
Explanation:This patient is presenting with a severe placental abruption causing fetal death and shock in the mother. The most appropriate initial management for the patient is to treat her shock with blood transfusions and exclude or treat any coagulation disorder resulting from the abruption. Delivery also needs to be expedited to remove the dead foetus. An amniotomy is usually all that is required to induce spontaneous labour as the uterus is usually very irritable. Spontaneous labour is likely to occur in this case, where the cervix is already 4 cm dilated and fully effaced.
Caesarean section is rarely needed to be done when the foetus is already dead.
Vaginal prostaglandin and an oxytocin (Syntocin®) infusion are not needed and unlikely to be required.
Ultrasound examination to confirm the diagnosis and fetal death is also unnecessary given the clinical and Doppler findings.
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This question is part of the following fields:
- Obstetrics
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Question 22
Correct
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A 53 year old lady presents to clinic due to vulval itch and discolouration. examination reveals pale white discoloured areas to the vulva. A biopsy shows epidermal atrophy with sub-epidermal hyalinization and deeper inflammatory infiltrate. What is this characteristic of?
Your Answer: Lichen Sclerosus
Explanation:Lichen sclerosus is characterized by hypopigmented atrophic plaque in the perineal region along with features of pruritis and dyspareunia.
It is more common in post menopausal women and on histology there is epidermal atrophy, inflammatory infiltrate in the dermis and basal layer degeneration.Vitiligo is characterised by hypopigmentation but without any other symptoms.
Extramammary Paget’s disease is characterized by erythematous plaque located mostly in the perianal region but its histology is different.
Lichen simplex chronicus is a chronic scaly pruritic condition characterized by itchy papules and plaques plus lichenification and it mostly results from chronic irritation and itching of the area. -
This question is part of the following fields:
- Clinical Management
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Question 23
Correct
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A 32-year-old mother with a 9-year-old child is considering having a second child. Her first pregnancy was complicated by puerperal psychosis. Following electroconvulsive therapy (ECT), she promptly recovered and has been well until now. She is in excellent health and her husband has been very supportive. According to patient files, she was noted to be an excellent mother. What would be the most appropriate advice?
Your Answer: There is a 15-20% chance of recurrence of psychosis postpartum.
Explanation:Puerperal psychosis seems to be mainly hereditary and closely associated with bipolar disorder especially the manic type, rather than being a distinct condition with a group of classical symptoms or course. Postpartum psychoses typically have an abrupt onset within 2 weeks of delivery and may have rapid progression of symptoms. Fortunately, it is generally a brief condition and responds well to prompt management. If the condition is threatening the mother and/or baby’s safety, hospital admission is warranted. A patient can present with a wide variety of psychotic symptoms ranging from delusion, passivity phenomenon, catatonia, and hallucinations. While depression and mania may be the predominating features, it is not surprising to see symptoms such as confusion and stupor. Although the rate of incidence is about 1 in 1000 pregnancies, it is seen in about 20% of women who previously had bipolar episodes prior to pregnancy. It has not been shown to be linked with factors such as twin pregnancies, stillbirth, breastfeeding or being a single parent. However, it might be more commonly seen in women who are first-time mothers and pregnancy terminations.
The risk of recurrence is 20%. Unfortunately, there is no specific treatment guideline but organic causes should first be ruled out. First generation/typical anti-psychotics are often associated with extrapyramidal symptoms. Nowadays, atypical antipsychotics such as risperidone or olanzapine can be used along with lithium which is a mood stabiliser. As of now, there hasn’t been any significant side effects as a result of second generation antipsychotic use in pregnancy. While women are usually advised to stop breast-feeding, it might be unnecessary except if the mother is being treated with lithium which has been reported to cause side effects on the infants in a few instances. ECT is considered to be highly efficacious for all types of postpartum psychosis and may be necessary if the mother’s condition is life-threatening to herself or/and the baby. If untreated, puerperal psychosis might persist for 6 months or even longer.
The options of saying ‘in view of her age and previous problem, further pregnancies are out of the question’ and so is ‘By all means start another pregnancy and see how she feels about it. If she has misgivings, then have the pregnancy terminated.’ are inappropriate.
As mentioned earlier, considering there is a 20% chance of recurrence it is not correct to say that since she had good outcomes with her first pregnancy, the risk of recurrence is minimal.
Anti-psychotics are not recommended to be used routinely both during pregnancy and lactation due to the absence of long-term research on children with intrauterine and breastmilk exposure to the drugs. Hence it is not right to conclude that ‘if she gets pregnant then she should take prophylactic antipsychotics throughout the pregnancy’ as it contradicts current guidelines. Each case should be individualised and the risks compared with the benefits to decide whether anti-psychotics should be given during pregnancy. It is important to obtain informed consent from both the mother and partner with documentation.
Should the mother deteriorates during the pregnancy that she no longer is capable of making decisions about treatment, then an application for temporary guardianship should be carried out to ensure that she can be continued on the appropriate treatment.
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This question is part of the following fields:
- Obstetrics
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Question 24
Correct
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Question 25
Correct
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A patient undergoes oophorectomy and the ovarian veins are ligated. Which vein does the left ovary drain into?
Your Answer: Left renal
Explanation:When it comes to questions on venous drainage the ovarian vein is likely to be a common question given its varied drainage depending on laterality. The right ovarian vein travels through the suspensory ligament of the ovary and generally joins the inferior vena cava whereas the left ovarian vein drains into the left renal vein.
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This question is part of the following fields:
- Anatomy
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Question 26
Incorrect
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A 46-year-old woman complains of ulceration with bloody discharge around her right nipple accompanied by redness, excoriations, and severe itchiness. What is the most likely diagnosis?
Your Answer: Duct papilloma
Correct Answer: Paget’s disease of the breast
Explanation:Paget’s disease of the breast is a type of cancer that outwardly may have the appearance of eczema, with skin changes involving the nipple of the breast. Symptoms may include redness of the nipple skin and crusting may occur around the area. In more advance cases, symptoms may include itching or a burning pain in the nipple.
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This question is part of the following fields:
- Gynaecology
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Question 27
Incorrect
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A 30 year old female with type I diabetes for 13 years, came for pre-pregnancy counselling. Which of the following is the most suitable advise for her?
Your Answer: She should aim to have a pre-pregnancy HbA1c of <48 mmol/mol (6.5%)
Correct Answer:
Explanation:According to NICE guidelines women with type I diabetes, who are expecting a child should aim to keep their HbA1c level[1] below 48 mmol/mol (6.5%) without causing problematic hypoglycaemia. Women with diabetes whose HbA1c level is above 86 mmol/mol (10%) should be strongly advised not to get pregnant because of the associated risks. The risks are higher with chronic diabetes. There is an increased risk to the foetus or mother due to diabetes in pregnancy. Women who are waiting to become pregnant should take folic acid (5 mg/day) until 12 weeks of gestation to reduce the risk of having a baby with a neural tube defect.
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This question is part of the following fields:
- Gynaecology
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Question 28
Correct
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What is the role of DHEA produced by the fetal adrenal glands?
Your Answer: Stimulate placenta to form oestrogen
Explanation:Dehydroepiandrosterone (DHEA) is a steroid hormone synthesised from cholesterol (via Pregnenolone) by the adrenal glands. The foetus manufactures DHEA, which stimulates the placenta to form oestrogen, thus keeping a pregnancy going. Production of DHEA stops at birth, then begins again around age seven and peaks when a person is in their mid-20s
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This question is part of the following fields:
- Endocrinology
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Question 29
Incorrect
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In threatened abortion, which one of the following items is TRUE?
Your Answer: The cervix is open
Correct Answer: More than 50% will abort
Explanation:Threatened abortion:
– Vaginal bleeding with closed cervical os during the first 20 weeks of pregnancy
– Occurs in 25% of 1st-trimester pregnancies
– 50% survival
More than half of threatened abortions will abort. The risk of spontaneous abortion, in a patient with a threatened abortion, is less if fetal cardiac activity is present. -
This question is part of the following fields:
- Obstetrics
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Question 30
Incorrect
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The ascending colon drains into the superior mesenteric vein (SMV). What vein does the SMV drain into?
Your Answer: Inferior vena cava
Correct Answer: Hepatic portal vein
Explanation:The superior mesenteric vein joins the splenic vein to form the hepatic portal vein.
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This question is part of the following fields:
- Anatomy
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