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Question 1
Correct
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At the time of delivery, if there is a laceration of perineal body but not the anal sphincter, this type of laceration is classified as?
Your Answer: Second degree
Explanation:Perineal tears are common at the time of child birth. First degree perineal laceration means that the wound is so small that it doesn’t require any stitches and usually heals on its own. 2nd degree means that skin and smooth muscles are both torn. 3rd degree tear means that the tear is beyond the perineal muscles and the muscles surrounding the anal canal, while in 4th degree, the perineal tear goes through the anal sphincter up to the rectum.
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This question is part of the following fields:
- Anatomy
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Question 2
Incorrect
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Which spinal segment is the lumbar plexus derived from?
Your Answer: L1-L3
Correct Answer: T12-L4
Explanation:The lumbar plexus is formed via contributions from the T12-L4 spinal cord segment. The plexus is responsible for the motor and sensory innervation of portions of the lower extremities and some parts of the lower abdomen and pelvis. Nerves arising from the plexus include the Iliohypogastric, ilioinguinal, genitofemoral, lateral femoral cutaneous, femoral nerve, obturator, and nerve to the lumbosacral trunk.
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This question is part of the following fields:
- Anatomy
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Question 3
Correct
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Spinnbarkheit is a term which means:
Your Answer: Threading of the cervical mucous
Explanation:Spinnability (or Spinnbarkeit), which measures the capacity of fluids to be drawn into threads, represents an indirect measurement of the adhesive and elastic properties of mucus.
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This question is part of the following fields:
- Physiology
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Question 4
Correct
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One year ago, Pap smear was done at your clinic for a 53 year old female patient. HPV type 42 was detected and reported as LSIL. A repeat pap smear after 12 months shows no change.
What is the next best step in management?Your Answer: Refer for colposcopy
Explanation:The management of low-grade squamous intraepithelial lesions (LSIL) on cervical cytology in women ages 25 years or older depends upon whether the patient underwent high-risk human papillomavirus (HPV) testing.
Women in this age group comprise two different populations in terms of cervical cancer screening strategies. Professional organizations recommend that women ages 25 to 29 years be screened with cytology alone, while women 30 years or older should be screened with cytology and HPV co-testing. Thus, the American Society for Colposcopy and Cervical Pathology (ASCCP) prefers that women ages 25 to 29 years are not managed based upon HPV results, even if an HPV test was performed at the time of screening. For women with ages 30 years or older and HPV positive, colposcopy must be performed.
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This question is part of the following fields:
- Gynaecology
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Question 5
Correct
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The external anal sphincter is innervated by which nerves?
Your Answer: Inferior rectal
Explanation:The external anal sphincter is innervated by the inferior rectal branch of the pudendal nerve (S2-4) while the internal anal sphincter is innervated by autonomic nerves.
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This question is part of the following fields:
- Anatomy
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Question 6
Incorrect
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Pregnant patients are at higher risk of thromboembolism due to a hypercoagulable state. Which of the following clotting factors reduces during pregnancy?
Your Answer: Fibrinogen
Correct Answer: Factor XI
Explanation:Pregnancy is a hypercoagulable state, which means that risk of thromboembolism is increased. The main reason is an increase in clotting factors II, factor VII, fibrinogen, factor X and factor XII, whereas factors XI and factor XIII are reduced. Naturally occurring anticoagulants i.e. protein C and protein S are both decreased thus increasing the risk of thrombus formation.
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This question is part of the following fields:
- Clinical Management
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Question 7
Correct
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The following drugs cross the placenta to the foetus, EXCEPT:
Your Answer: Heparin
Explanation:Standard heparin, an effective treatment for antepartum thromboembolic disease, is thought to be safe for the foetus since it does not cross the placenta.
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This question is part of the following fields:
- Pharmacology
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Question 8
Incorrect
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Which of the following pubertal events is NOT mediated by gonadal oestrogen production?
Your Answer: Skeletal growth
Correct Answer: Pubic hair growth
Explanation:The role of androgens in the female includes acting as precursors for oestrogen production, anabolic effects, stimulation of axillary and pubic hair growth, sebum production, stimulation of bone formation, and stimulation of erythropoietin production in the kidneys.
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This question is part of the following fields:
- Physiology
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Question 9
Incorrect
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Which of the following drugs is most appropriate to use to stimulate lactation?
Your Answer: Metoclopramide
Correct Answer: Domperidone
Explanation:Domperidone and metoclopramide are D2 dopamine receptor antagonists. They are primarily used to promote gastric motility. They are also known as galactagogues and they promote the production of milk. Cabergoline and bromocriptine are prolactin inhibitors and they reduce milk production.
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This question is part of the following fields:
- Endocrinology
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Question 10
Correct
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A patient comes to your office with her last menstrual period 4 weeks ago. She thinks that she may be pregnant because she has not had her period yet, but denies any symptoms such as nausea, fatigue, urinary frequency, or breast tenderness.
As she has a history of previous ectopic pregnancy, she is very anxious to find out and wants to be sure to get early prenatal care.
Among the following actions which is most appropriate at this time?Your Answer: Order a serum quantitative pregnancy test.
Explanation:Nausea, fatigue, breast tenderness, and increased frequency of urination are the most common symptoms of pregnancy, but their presence is not considered definitive as they are nonspecific symptoms which are not consistently found in early pregnancy, also these symptoms can occur even prior to menstruation.
In pregnancy a physical examination will reveal an enlarged uterus which is more boggy and soft, but these findings are not apparent until after 6th week of gestation. In addition, other conditions like adenomyosis, fibroids, or previous pregnancies can also result in an enlarged uterus which is palpable on physical examination.
An abdominal ultrasound will not demonstrate a gestational sac until a gestational age of 5 to 6 weeks, nor will it detect an ectopic pregnancy soon after a missed menstrual period, therefore it is not indicated in this patient.
A Doppler instrument will detect fetal cardiac action usually after 10 weeks of gestation.
A sensitive serum quantitative pregnancy test can detect placental HCG levels by 8 to 9 days post-ovulation and is considered as the most appropriate next step in evaluation of this patient.
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This question is part of the following fields:
- Obstetrics
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Question 11
Correct
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A 32-year-old woman who is multigravida and with breech presentation presented to the emergency department for vaginal delivery. Upon spontaneous rupture of the membranes, bradycardia and variable deceleration was noted on the fetal heart rate monitoring.
Vaginal examination was performed and revealed cord prolapse that is still pulsating.
Which of the following is considered the most appropriate next step in managing the patient?Your Answer: Arrange for emergency caesarean delivery
Explanation:Umbilical cord prolapse (UCP) occurs when the umbilical cord exits the cervical opening before the fetal presenting part. It is a rare obstetric emergency that carries a high rate of potential fetal morbidity and mortality. Resultant compression of the cord by the descending foetus during delivery leads to fetal hypoxia and bradycardia, which can result in fetal death or permanent disability.
Certain features of pregnancy increase the risk for the development of umbilical cord prolapse by preventing appropriate engagement of the presenting part with the pelvis. These include fetal malpresentation, multiple gestations, polyhydramnios, preterm rupture of membranes, intrauterine growth restriction, preterm delivery, and fetal and cord abnormalities.
The occurrence of fetal bradycardia in the setting of ruptured membranes should prompt immediate evaluation for potential cord prolapse.
In overt prolapse, the cord is palpable as a pulsating structure in the vaginal vault. In occult prolapse, the cord is not visible or palpable ahead of the fetal presenting part. The definitive management of umbilical cord prolapse is expedient delivery; this is usually by caesarean section.
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This question is part of the following fields:
- Obstetrics
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Question 12
Correct
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Regarding uterine fibroids, which of the following statements is false?
Your Answer: The risk of fibroids is increased by pregnancy
Explanation:Fibroids are a common gynaecological condition found in many women above the age of 35. They are however uncommon before puberty. They are most common in black women vs white women, and its prevalence increases from puberty to menopause. Risk factors for fibroids include increasing age, obesity and infertility. Protective factors, on the other hand, include pregnancy, as the risk of fibroids decreases with increasing numbers of pregnancies.
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This question is part of the following fields:
- Clinical Management
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Question 13
Incorrect
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High levels of alpha feto protein are found in all, EXCEPT?
Your Answer: Intrauterine fetal distress
Correct Answer: Trisomy 21
Explanation:Pregnant maternal serum AFP levels elevated: Neural tube defects (e.g., spina bifida, anencephaly); Omphalocele; Gastroschisis.
Pregnant maternal serum AFP low levels: Down syndrome
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This question is part of the following fields:
- Endocrinology
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Question 14
Incorrect
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A 26 year old female patient comes to a GP asking to see a gynaecologist for cervical screening test. She has no history of sexual intercourse and is not a lesbian.
What would you do next?Your Answer: You do cervical screening test and see her in clinic
Correct Answer: Reassure her there is no need for cervical screening test at this stage
Explanation:Women, who have never had sexual encounter, do not need cervical screening. However, any sort of sexual encounter (Lesbian or heterosexual) is considered a risk and the patient must be screened. Otherwise, routine cervical screening test can be performed every five years for woman 25-74 years who ever had sex with no evidence of cervical pathology. Perform a cervical screening test at the age of 25 or 2 years after first sexual intercourse-whichever is later in sexually active women. Perform cervical screening test in patients above 75 years if they request or if they never had any symptoms.
All other options are unacceptable.
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This question is part of the following fields:
- Gynaecology
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Question 15
Correct
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The following are true for dizygotic twins EXCEPT:
Your Answer: Both twins are identical & of the same sex
Explanation:Dizygotic means two (di) fertilized eggs (zygotes). Dizygotic twins occur when two eggs are fertilized by two separate sperm. Dizygotic twins are also known as fraternal or non-identical twins. They are the most common type of twins.
Unlike monozygotic twins (also known as identical twins), dizygotic twins do not share the same genes. Monozygotic twins share 100 percent of each other genes. Dizygotic twins share only 50 percent. This is the same genetic similarity found between siblings conceived and born at different times.
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This question is part of the following fields:
- Genetics
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Question 16
Correct
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A 47 year old women has a transvaginal ultrasound that shows a partially echogenic mass with posterior sound attenuation owing to sebaceous material and hair within the cyst cavity. What is the likely diagnosis?
Your Answer: Mature teratoma
Explanation:These are the most common ovarian tumours in young women. The most common form is the mature dermoid cyst (cystic teratoma). It can consist of a combination of all the type of tissues (mesenchymal, stromal and epithelial). Any mature tissue type can be present such as muscle, cartilage, bone, teeth and often hair. Treatment is cystectomy.
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This question is part of the following fields:
- Data Interpretation
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Question 17
Incorrect
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A 34-year-old woman presents with a two-year history of secondary infertility.
She has a three year old child who was fathered by the same partner. This first child was conceived spontaneously and delivered normally following a short labour.
Her medical history includes irregular menstrual cycles, with periods occurring every three to four months.
A pelvic ultrasound reveals 15-20 small cysts (4- 6 mm in diameter) in each ovary.
Semen analysis, of her partner, shows a sperm count of ten million per mL, with 50% motility and 30% abnormal forms.
Which one of the following is the best next step to treat her infertility?Your Answer: Ovulation induction with gonadotrophins.
Correct Answer: Treatment with metformin.
Explanation:The clinical diagnosis of polycystic ovaries (PCO) is confirmed by the ultrasound. Therefore, the best next step to treat this woman’s infertility is to start treatment with metformin (correct answer). Patients with polycystic ovaries, frequently develop insulin resistance and metformin has been shown to be beneficial in this situation. Metformin treatment corrects any metabolic abnormalities and decreases insulin resistance resulting in a return of normal ovulatory menstrual cycles and a rapid improvement in fertility.
Additional treatment with clomiphene citrate may be required in some patients but gonadotrophin therapy is no longer commonly used.
Clomiphene citrate could also have been recommended as a possible next treatment option since the available data indicate that both clomiphene and metformin are equally effective.
Laparoscopic ovarian drilling has been used previously to treat polycystic ovaries; however, it is only used nowadays when all other treatment methods have been ineffective.
Similarly, gonadotrophin therapy or in vitro fertilisation would not be the best next step to treat the infertility and they are used when other treatment options have not provided the required results.
Even though changes in the semen analysis have been noted since the first pregnancy was achieved, these are not likely to be the cause of the secondary infertility, particularly because the current semen analysis is not significantly abnormal. Therefore, it is unlikely that donor insemination would be needed.
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This question is part of the following fields:
- Gynaecology
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Question 18
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 19
Incorrect
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A 19 year old patient on Lamotrigine 125 mg twice a day for the past two years has recently been prescribed Microgynon 30 as a contraceptive before she leaves for Uni. What could the main concern be?
Your Answer: Lamotrigine is a strong enzyme inducer and may inhibit contraceptive effect
Correct Answer: Combined contraceptive may reduce Lamotrigine levels and increase seizure risk
Explanation:Lamotrigine, a drug used to treat epilepsy, is less effective when taken with combined oral contraceptives. The oestrogen component of the pill decreases the circulating levels of Lamotrigine, increasing the risk of seizures. The combination is therefore classified as a UKMEC 3, as the risk of the drug combination may outweigh the benefit. As an alternative, the progesterone-only pill, depo progesterone, Mirena or the copper IUD may be considered as there is no restriction on concomitant use. Lamotrigine is not metabolised through cytochrome P450 like other antiepileptic drugs such as carbamazepine and phenytoin, neither is it an enzyme inhibitor.
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This question is part of the following fields:
- Clinical Management
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Question 20
Correct
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A fibroid is a type of
Your Answer: Leiomyoma
Explanation:A fibroid is a benign smooth muscle tumour or Leiomyoma. As such it is something of a misnomer. Leiomyosarcoma and Angioleiomyoma are malignant tumours of smooth muscle under the WHO sort tissue tumour classification Rhabdomyoma is a skeletal muscle tumour Myofibroma is seen in fibromatosis
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This question is part of the following fields:
- Clinical Management
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Question 21
Incorrect
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All of the following statements regarding episiotomy are true, except?
Your Answer: Median (midline) episiotomy is generally considered to be less painful then mediolateral episiotomy
Correct Answer: The earlier the episiotomy is done during delivery, generally the more beneficial it will be in speeding up delivery
Explanation:The best time of the episiotomy is when the presenting part becomes visible during the contractions. If the episiotomy is performed at the proper time, less time will be required for the delivery. However, if its done too late, it causes excessive stretching of the pelvic floor and further potential lacerations.
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This question is part of the following fields:
- Obstetrics
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Question 22
Correct
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Which of the following nerves passes through the inguinal canal?
Your Answer: Ilioinguinal nerve
Explanation:The contents of the inguinal canal is the ilioinguinal nerves, the round ligament of uterus in the females and the spermatic cord with its contents in males.
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This question is part of the following fields:
- Anatomy
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Question 23
Correct
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A 36-year-old obese woman presents to your office for advice regarding pregnancy.
Her body mass index is 40, and she is normotensive and has a normal serum glucose level. On examination she was tested positive for glucose in urine.
What would be your advice to her?Your Answer: She will be checked for pre-existing diabetes in early pregnancy and, for gestational diabetes at 26 weeks
Explanation:Counselling her about the risks associated with obesity during pregnancy will be the best possible advice to give this patient. A combined follow up by an obstetrician and a diabetes specialist at a high-risk pregnancy clinic is required to formulate the best ways in management of gestation with obesity.
An oral glucose tolerance test should be done at 26 weeks of her pregnancy, along with advising her on controlling her weight by diet and lifestyle modifications. During the early weeks of their pregnancy all obese patients must be routinely tested for pre-existing diabetes.It is highly inappropriate to advice her not to get pregnant.
Without making a proper diagnosis of diabetes, it is wrong to ask her to start oral hypoglycemic agent and/or insulin.
Checking urinary proteins is not indicated at this stage, but can be considered as a part of antenatal check up.
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This question is part of the following fields:
- Obstetrics
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Question 24
Correct
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Regarding Turner syndrome which of the following statements is true?
Your Answer: Only 1% of affected foetuses will survive to term
Explanation:The incidence of 45,XO turner syndrome is around 1 in 8000 live births. Approximately 1% of monosomy X female embryos survive. Phenotypically they are females and 90% do not develop secondary sexual characteristics and hormone replacement is required.
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This question is part of the following fields:
- Genetics
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Question 25
Correct
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A lady who is 29-weeks pregnant, comes to a general practice, complaining of a sudden gush of clear fluid.
On Speculum examination, premature rupture of membranes is confirmed with closed cervix.
In addition to transferring patient to a tertiary care, what is the most appropriate in the management of this case?Your Answer: Betamethasone
Explanation:This patient who is at her 29 weeks of pregnancy, presented with sudden gush of clear fluid and Speculum examination has confirmed premature rupture of membrane (PROM).
Approximately, 50% of PROM progress to labour within 24 hours and in the remaining, 80% within seven days. The most important next step of management in this case is transferring this patient to tertiary care hospital as soon as possible. It is equally important to give corticosteroid therapy, like Betamethasone, if delivery prior to 34 weeks is likely to occur, as it will help in fetal lung maturity.
Cardiotocography (CTG) is usually not available in general practice settings and it can be done only while in the hospital. If CTG shows any abnormality or if there is any presence of infection it is better to induce labor.
Salbutamol and nifedipine are of no use in this case, as the patient is not in labour and does not require tocolytics.
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This question is part of the following fields:
- Obstetrics
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Question 26
Incorrect
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Regarding the closure of the ductus arteriosus (DA) after birth which of the following most accurately describes the mechanisms leading to closure of the DA?
Your Answer: Increased arterial pO2, decreased bradykinin & decreased Prostaglandin E2
Correct Answer: Increased arterial pO2, increased bradykinin & decreased Prostaglandin E2
Explanation:Normal closure of the ductus arteriosus (DA) is brought about by a number of mechanisms. Upon delivery the new born babies first breath inflates the lungs and this causes a rise in pO2. Oxygen is known to cause constriction of the DA in vivo and in vitro. In addition the decreased vascular resistance means the pressure within the lumen of the DA drops aiding closure. In addition on inflation of the lungs, the lungs produce bradykinin which stimulates smooth muscle constriction of the ductus. The most important factor is thought to be the drop in Prostaglandin E2. Prostaglandin E2 maintains patency of the Ductus in the unborn child but after birth is metabolised in the lungs and its levels fall rapidly within 3 hours of birth.
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This question is part of the following fields:
- Embryology
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Question 27
Correct
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From which germ cell layer does the GI tract initially develop?
Your Answer: Endoderm
Explanation:GI Tract initially forms via gastrulation from the endoderm of the trilaminar embryo around week 3. It extends from the buccopharyngeal membrane to the cloacal membrane. Later in development there are contributions from all three germ cell layers.
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This question is part of the following fields:
- Embryology
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Question 28
Correct
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What is the most common causative organism in Fitzhugh Curtis syndrome and ophthalmic neonatorum?
Your Answer: Chlamydia trachomatis
Explanation:A rare complication of pelvic inflammatory disease is Fitz Hugh Curtis syndrome which is perihepatitis leading to the formation of adhesions between the liver and the peritoneal surface. It is most commonly caused by chlamydia and gonorrhoea. Ophthalmia neonatorum is conjunctivitis which is also caused by these pathogens.
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This question is part of the following fields:
- Clinical Management
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Question 29
Correct
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A 37-year-old woman visits your office seeking oral contraceptive guidance. She is currently taking Microgynon 30 and is pleased with the results. She is married with two children, does not smoke, and is in good health.
Her blood pressure is 150/100mmHg, according to your examination. The blood pressure remains the same after 20 minutes.
Which of the following is the most appropriate next step in management?Your Answer: Start her on progestogen-only pills (POPs)
Explanation:The progestogen-only pill (POP) is a contraceptive option for women who have high blood pressure either induced by use of combined oral pills or due to other causes; as long as it is well controlled and monitored. Combined oral contraception (COC) and Depo-Provera have been implicated in increased cardiovascular risk following use. High blood pressure has been theorized to be the critical path that leads to this increased risk. POP is the recommended method for women who are at risk of coronary heart disease due to presence of risk factors like hypertension.
Stopping OCP will risk in the patient getting pregnant. Cessation of oestrogen usually reverses the blood pressure back to normal, Hence, all other options are incorrect.
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This question is part of the following fields:
- Gynaecology
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Question 30
Correct
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All of the following statements regarding human chorionic gonadotrophin are true except::
Your Answer: It's level doubles every 48 hours in ectopic pregnancy
Explanation:In normal pregnancy the levels of hCG doubles after every 48-72 hours but in case of ectopic pregnancy the levels of hCG are lower than the normal. It is produced by the placenta and its main role is nourishment of the egg after implantation. Its levels reached a peak at 8-10 weeks of pregnancy and after that the levels decreases for the remainder of pregnancy. In hydatiform mole and trophoblastic diseases its the main hormone for diagnosis of the disease because the levels are highly elevated.
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This question is part of the following fields:
- Physiology
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Question 31
Incorrect
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A patient in a high-risk pregnancy clinic has a past obstetrical history of placenta previa and caesarean section has a breech presentation at 36 weeks gestation.
Which of the following is considered a risk factor in increasing the chance of term breech presentation?Your Answer: Polyhydramnios
Correct Answer: All of the above
Explanation:Breech presentation refers to the foetus in the longitudinal lie with the buttocks or lower extremity entering the pelvis first.
Clinical conditions associated with breech presentation include those that may increase or decrease fetal motility, or affect the vertical polarity of the uterine cavity. Prematurity, multiple gestations, aneuploidies, congenital anomalies, Mullerian anomalies, uterine leiomyoma, and placental polarity as in placenta previa are most commonly associated with a breech presentation. Also, a previous history of breech presentation at term increases the risk of repeat breech presentation at term in subsequent pregnancies.
Conditions that change the vertical polarity or the uterine cavity, or affect the ease or ability of the foetus to turn into the vertex presentation in the third trimester include:
– Mullerian anomalies
– Placentation
– Uterine leiomyoma
– Prematurity
– Aneuploidies and fetal neuromuscular disorders
– Congenital anomalies
– Polyhydramnios and oligohydramnios
– Laxity of the maternal abdominal wall. -
This question is part of the following fields:
- Obstetrics
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Question 32
Correct
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A 29-year-old woman at 28 weeks of pregnancy was diagnosed with gestational diabetes. At a high-risk pregnancy clinic, she was considered to have been managed well until 38 weeks when she delivered a healthy 4-kg baby via vaginal delivery without any complications.
Which of the following is the next step in managing her gestational diabetes?Your Answer: 75g oral glucose tolerance test performed 6 to 8 weeks after delivery
Explanation:The Australasian Diabetes in Pregnancy Society recommends a 50 or 75 g glucose challenge at 26–28 weeks in all pregnant women. An OGTT should be performed if the test result is abnormal: 1 hour values after a 50 or 75 g glucose challenge exceeding 7.8 or 8.0 mmol/L respectively.
If a woman has had gestational diabetes, a repeat OGTT is recommended at 6–8 weeks and 12 weeks after delivery. If the results are normal, repeat testing is recommended between 1 and 3 years depending on the clinical circumstances.
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This question is part of the following fields:
- Obstetrics
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Question 33
Correct
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Branches V2 and V3 of the trigeminal nerve develop from which pharyngeal arch?
Your Answer: 1st
Explanation:Trigeminal nerve has three divisions, the first is the ophthalmic division that does not originate from any of the pharyngeal arches, the second and third divisions, namely, the maxillary and the mandibular region develop from the first pharyngeal arch.
Pharyngeal Arches:
1st = Trigeminal V2 & V3 (CN V)
2nd = Facial (CN VII)
3rd = Glossopharyngeal (CN IX)
4th and 6th = Vagus (CN X) -
This question is part of the following fields:
- Embryology
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Question 34
Incorrect
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Which organism is the most common cause of puerperal sepsis?
Your Answer: Staphylococcus aureus
Correct Answer: Group A Streptococcus
Explanation:Puerperal sepsis is defined as sepsis occurring after birth until 6 weeks postnatal. The most common cause of puerperal sepsis is Group A streptococcus. Until 1937, puerperal sepsis was the major cause of maternal mortality. The discovery of sulphonamides in 1935 and the simultaneous reduction in the virulence of the haemolytic streptococcus resulted in a dramatic fall in maternal mortality.
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This question is part of the following fields:
- Clinical Management
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Question 35
Correct
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A 28-year-old woman who is at the 18th week of gestation presented to the medical clinic due to a vaginal discharge. Upon history taking, it was revealed that she had a history of preterm labour at 24 weeks of gestation during her last pregnancy. Upon examination, the presence of a clear fluid coming out of the vagina was noted.
Which of the following is considered to be the best in predicting pre-term labour?Your Answer: Cervical length of 15mm
Explanation:Preterm birth is the leading cause of neonatal morbidity and mortality not attributable to congenital anomalies or aneuploidy. It has been shown that a shortened cervix is a powerful indicator of preterm births in women with singleton and twin gestations – the shorter the cervical length, the higher the risk of spontaneous preterm birth. Ultrasound measurements of the cervix are a more accurate way of determining cervical length (CL) than using a digital method.
25 mm has been chosen as the ‘cut off’ at above which a cervix can be regarded as normal, and below which can be called short. A cervix that is less than 25 mm may be indicative of preterm birth.
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This question is part of the following fields:
- Obstetrics
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Question 36
Correct
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Which of the following factors as shown to decrease ovarian cancer risk?
Your Answer: Taking statins
Explanation:Factors shown to decrease risk of ovarian cancer are:
– Oral contraceptive use
– Higher Parity
– Breast feeding
– Hysterectomy
– Tubal Ligation
– Statins
– SLE -
This question is part of the following fields:
- Epidemiology
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Question 37
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 38
Incorrect
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A patient attends the maternity unit as her waters have broken but she hasn't had contractions. She is 39+6 weeks gestation. Speculum examination confirms prelabour rupture of membranes. What is the likelihood of spontaneous labour starting within 24 hours?
Your Answer: 40%
Correct Answer: 60%
Explanation:In pregnancy, term refers to the gestational period from 37 0 to 41 6 weeks. Preterm births occur between 24 0 and 36 6 weeks. 60% of the women will go into labour with in 24 hours in PPROM. After 24 hours have past without any contraction and the gestation age is more than 34 week than prostaglandins can be used to augment labour.
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This question is part of the following fields:
- Clinical Management
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Question 39
Correct
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A 25 year old female with her LRMP 8 weeks ago, presented with severe abdominal pain and per vaginal bleeding. On examination there was tenderness over her left iliac region. Her pulse rate was 110 bpm and blood pressure was 90/65mmHg. Which of the following is the most appropriate management?
Your Answer: Immediate laparotomy
Explanation:A ruptured ectopic pregnancy is the most probable diagnosis. As she is in shock (tachycardia and hypotension) immediate laparotomy is needed.
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This question is part of the following fields:
- Gynaecology
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Question 40
Correct
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Placental production of hPL, hCG, Oestrogen and Progesterone are examples of which type of mechanism
Your Answer: Endocrine
Explanation:Endocrine hormones are released from their site of origin and travel through the blood to act on other distant target organs. Autocrine hormones act within the same cell and exocrine glands secrete their products into ducts.
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This question is part of the following fields:
- Endocrinology
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Question 41
Correct
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What is the normal pH value of an umbilical arterial sample of a new born term baby?
Your Answer: 7.2
Explanation:The normal range for a term baby is pH: 7.18 – 7.38, and preterm pH: 7.14 – 7.4. A pH below 7.1 therefore indicates acidosis.
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This question is part of the following fields:
- Physiology
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Question 42
Correct
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A 20-year-old nulligravid woman comes to the office for a routine checkup, as she is concerned about having gained 4.5 kg over the last year. She believes that the gain is related to her oral contraceptive pills.
Patient takes low-dose ethinyl estradiol
orethindrone daily. Prior to starting the pills, she had regular but heavy periods lasting for 4-5 days. Patient used to miss her school every month, on the first day of her period, due to severe cramping. Her pain symptoms resolved 3 months after starting the pills and she takes no other medications. Patient's coitarche was at the age of 18 and she has had 2 partners since then. Patient and her current partner use condoms inconsistently.
On examination her vital signs are normal, with a BMI of 27 kg/m2 and physical examination is unremarkable.
Among the following which is the most appropriate advice for this patient?Your Answer: Reassure that the weight gain is not related to combined OCPs
Explanation:Breakthrough bleeding, breast tenderness, nausea, bloating, amenorrhea, hypertension, venous thromboembolic disease, increased risk of cervical cancer with decreased risk of ovarian & endometrial cancer, liver disorders like hepatic adenoma and increase in triglycerides due to estrogen component are the common side effects & risks of using combination oral contraceptives.
Patient in the given case mentioned symptoms of primary dysmenorrhea, which is recurrent lower abdominal pain associated with menstruation. Combination estrogen-progestin oral contraceptive pills (OCPs) are considered as the first-line treatment for dysmenorrhea in sexually active patients as OCPs help to reduce pain by thinning the endometrial lining, reducing prostaglandin release and by decreasing uterine contractions.
Nausea, bloating and breast tenderness, are considered as the early side effects of OCPs and will usually improve with continued use. The most common side effect is breakthrough bleeding which is usually associated with lower estrogen doses and other adverse effects caused by the pills include hypertension, increased risk of cervical cancer and venous thromboembolism. Although common perception considers weight gain as a side effect, several studies have shown that no significant weight gain is associated with OCPs, particularly with low-dose formulations. Considering this, the patient should be reassured that her weight gain is not associated with regular use of OCPs.In patients who are not sexually active, nonsteroidal anti-inflammatory drugs are considered as the first-line treatment for primary dysmenorrhea. As stopping contraception will increase this Patient’s risk of unintended pregnancy this is not advisable to her.
Switching the patient to a copper intrauterine device (IUD) will decrease systemic side effects, but as its inflammatory reaction in the uterus may increase pain symptoms, copper IUD is not recommended for patients with dysmenorrhea.
As Medroxyprogesterone will increase body fat and decrease lean muscle mass resulting in weight gain is not a good option for this patient. Also medroxyprogesterone due to its risk of significant loss of bone mineral density, is not recommended for adolescents or young women. So it can be used in this age group only if other options are unacceptable.
Presence of estrogen component is the main reason behind the side effects of combination OCPs. Progesterone-only pills have relatively fewer side effects but as they do not inhibit ovulation, they are less effective for treating dysmenorrhea and for contraception.
Combination oral contraceptive pills are the first-line therapy for primary dysmenorrhea in sexually active patients. Its side effects include breakthrough bleeding, hypertension, and increased risk of venous thromboembolism. Researches proves that weight gain is usually not an adverse effect of OCPs.
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This question is part of the following fields:
- Obstetrics
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Question 43
Incorrect
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Which of the following regarding the use of tocolytics is true?
Your Answer: Use of a tocolytic drug reduces neonatal morbidity but not mortality
Correct Answer: Use of a tocolytic drug is not associated with a clear reduction in perinatal or neonatal mortality, or neonatal morbidity
Explanation:Tocolytics are used to suppress contractions. The Canadian preterm labour trial which remains a very influential tocolytic trial to date concluded that tocolytics such as a beta agonist have no significant benefit on perinatal mortality or morbidity or prolong pregnancy to term however it did reduce the number of women delivering within 2 days by 40%. This 48 hour window is the only reason for the use of tocolytics.
Choice of tocolytic (NICE)
1st line: Nifedipine
2nd line: Oxytocin receptor antagonists e.g. atosiban -
This question is part of the following fields:
- Clinical Management
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Question 44
Incorrect
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What is the male infertility rate in CF patients?
Your Answer: 40%
Correct Answer: 98%
Explanation:Cystic fibrosis is the most common fetal genetic disease in Caucasians and has an autosomal recessive inheritance. It is caused by an abnormal chloride channel due to a defect in the CFTR gene. Complications range from haemoptysis, respiratory failure, biliary cirrhosis, diabetes and male infertility. Men with CF are infertile in 98% of the cases due to failure of development of the vas deference.
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This question is part of the following fields:
- Clinical Management
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Question 45
Incorrect
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A 33 year old lady in her first trimester of pregnancy presented with loss of weight, abdominal pain and frequent episodes of vomiting. Her vital signs are normal. She has been given a cyclizine injection but without any significant improvement. The next step would be?
Your Answer: IV antiemetics
Correct Answer: IV steroids
Explanation:In hyperemesis gravidarum, IV corticosteroids can be given to reduce vomiting, if the patient is not responding to standard anti emetics.
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This question is part of the following fields:
- Gynaecology
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Question 46
Correct
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Herpes Simplex is which type of virus
Your Answer: double stranded DNA
Explanation:Herpes simplex is a double stranded DNA virus. There are two viral types, HSV-1 and HSV-2. The majority of orolabial infections are caused by HSV-1. These infections are usually acquired during childhood through direct physical contact such as kissing. Genital herpes is a sexually transmitted infection and is most commonly caused by HSV-2.
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This question is part of the following fields:
- Microbiology
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Question 47
Correct
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Which one of the following statements best suits Androgen insensitivity syndrome?
Your Answer: Gonadectomy must be performed after puberty because of the increased risk of malignancy
Explanation:Androgen insensitivity syndrome patients have 46XY chromosomes. They are males by genotype but appear as female because of insensitivity to male hormones. It is advisable to perform gonadectomy in these patients after puberty because these patients are at increased risk of developing malignancy.
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This question is part of the following fields:
- Embryology
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Question 48
Incorrect
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A 35-year-old Aboriginal woman is found to be lgM positive, but lgG negative after exposure to a child with rubella during the first trimester of pregnancy.
On laboratory investigation, rubella infection is confirmed as repeated serology testing shows not only a positive lgM, but also a rising titers of lgG.
Among the following next steps in management, which one is considered to be the most appropriate?Your Answer: Check rubella serology again and get the test reported from another laboratory
Correct Answer: Termination of the pregnancy
Explanation:Antenatal screening for rubella IgG is a routine recommended for all pregnant women at their first visit. All pregnant women who have a history of contact with rubella or any clinical features consistent with rubella –like illness should be screened for the presence of rising antibody titre and / or rubella specific IgM. Serological confirmation is mandatory for diagnosing rubella.
As in this case scenario, positive lgM for rubella indicates active rubella infection, in such cases it is recommended to repeat the test. If lgM is still positive, it confirms rubella infection. No further testing from another laboratory is required.
The risk for fetal infection and damage is higher if rubella infection occurs during the first trimester of pregnancy, which is 85% in the first two months of pregnancy and 50 -80% in the third month. Therefore, termination of pregnancy is usually recommended in this situation. NHIG has been used in trials for prophylaxis and prevention of congenital rubella syndrome after contact to a case with rubella infection, but the results have been discouraging, therefore, it is not advisable.
In the given case, rubella infection has been established already, so NHIG will not be of any benefit as primary prevention.
Rubella-containing vaccines like MMR vaccine is a live attenuated vaccine are contraindicated throughout pregnancy, it should be avoided; and women who remain susceptible to rubella should receive MMR vaccine postpartum.
Risk of fetal infection and/or fetal damage or for development of congenital rubella syndrome is related to the timing of maternal infection. Cases with Primary infection is found to be in higher risk
In cases of asymptomatic re-infection with a good history of previous positive serology, even though it is difficult to quantify, the risk of fetal infection has been reported to be < 5 percent. Congenital rubella syndrome following maternal re-infection is considered rare particularly if re-infection occurs after 12 weeks. If the clinical picture is typically of rubella or if possibility of previous immunity is inconclusive based on serology, then the risk is assumed to be the same as that of primary infection. -
This question is part of the following fields:
- Obstetrics
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Question 49
Correct
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Which of the following is probably responsible for physiologic hyperventilation during pregnancy?
Your Answer: Increased progesterone production
Explanation:Progesterone gradually increases during the course of pregnancy, from 25 ng⋅mL−1 at 6 weeks’ to 150 ng⋅mL−1 at 37 weeks’ gestation. Progesterone acts as trigger of the primary respiratory centre by increasing the sensitivity of the respiratory centre to carbon dioxide, as indicated by the steeper slope of the ventilation curve in response to alveolar carbon dioxide changes. Progesterone alters the smooth muscle tone of the airways resulting in a bronchodilator effect. It also mediates hyperaemia and oedema of mucosal surfaces, causing nasal congestion.
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This question is part of the following fields:
- Physiology
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Question 50
Correct
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All are true about monozygotic pregnancy, EXCEPT:
Your Answer: The 1st commonly presents as breech
Explanation:The 1st commonly presents as cephalic. Monozygotic (MZ) twins originate when a single egg is fertilized to form one zygote, which then divides into two embryos. Although they share the same genotype they are not phenotypically identical.
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This question is part of the following fields:
- Genetics
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Question 51
Correct
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A 36-year-old woman presents to your clinic with cyclical mastalgia. Physical examination reveals that her breasts are normal. She has a family history of her mom who developed breast cancer at the age of 45 years and subsequently died from metastases. She states that her patient's maternal grandmother also had breast cancer before the age of 50.
The patient is on the oral contraceptive pill (OCP) and no other medications. She is generally healthy overall. Recent mammography results are also normal. An ultrasound of the breasts shows an uncomplicated cyst with no concerning features in the right breast.
Apart from advice about the use of simple analgesics and evening primrose oil for her mastalgia, which one of the following is the most appropriate management in the patient's follow-up regimen?Your Answer: Remain on the OCP, six-monthly clinical review, yearly mammography and ultrasound.
Explanation:This is a case of a woman who presented with cyclical breast pain that is on an OCP and with a family history of breast cancer. Those with a family history of breast cancer in more than one blood relative (parent, sibling, grandparent) have a significantly higher chance of developing breast cancer than women with no family history. Regular six-monthly clinical review and yearly mammographic screening, with or without ultrasound screening, should start at least five years before the age of the diagnosis in the blood relatives.
The consensus now is that any additional risk of breast cancer from the oestrogen in the oral contraceptive pill (OCP) is less than the risk of unwanted pregnancy when using alternative, and perhaps less effective, contraception. Thus, the patient would not be advised to stop the OCP.
With two blood relatives that developed breast cancer before the age of 50, this patient is in a high-risk group of developing breast cancer. Even so, 50% of such high-risk women will not develop a breast cancer in their lifetime. There are specialised familial cancer screening clinics are available for high-risk women where genetic testing can be discussed further. Women at high risk may electively have a bilateral subcutaneous mastectomy performed prophylactically which will bring the risk of breast cancer development to an irreducible minimum.
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This question is part of the following fields:
- Gynaecology
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Question 52
Incorrect
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Regarding the pelvic outlet, what structure marks the posterior boundary?
Your Answer: Ischial tuberosities
Correct Answer: Tip of the coccyx
Explanation:The bony pelvis is made up of a girdle with a central canal. The rim that surrounds the upper opening of the canal is called the pelvic inlet, while the lower rim is the called the pelvic outlet. The pelvic outlet is diamond-shaped and is bounded posteriorly by the tip of the sacrum, and anteriorly by the pubic symphysis, with its lateral boundaries being the ischial tuberosities and the sacrotuberous ligament.
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This question is part of the following fields:
- Anatomy
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Question 53
Correct
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A 24-year-old woman comes to your office at 38 weeks of gestation with a urinary dipstick result positive for leukocyte and nitrite. She is otherwise asymptomatic so you send her urine for culture and sensitivity test.
From the options below mentioned, which is the next best management for her?Your Answer: Prescribe her with Oral Cephalexin
Explanation:There is an association between 20 to 30% increase in the risk for developing pyelonephritis during later pregnancy and untreated cases of bacteriuria in pregnancy. This is due to the physiological changes occurring to urinary tract during pregnancy, it is also found that untreated bacteriuria can be associated with even preterm birth and low birth weight. Risk of symptomatic urinary tract infection (UTI) during pregnancy can be reduced by antibiotic treatment of asymptomatic bacteriuria
The most common pathogen associated with asymptomatic bacteriuria is Escherichia coli, which accounts to more than 80% of isolates and the second most frequently cultured uropathogen is Staphylococcus saprophyticus. Other Gram-positive cocci, like group B streptococci, are less common. Gram-negative bacteria such as Klebsiella, Proteus or other Enterobacteriaceae are the other organisms involved in asymptomatic bacteriuria.
Although the context patient is asymptomatic, her urine dipstick shows positive nitrite and leukocyte, suggestive of urinary tract infection, so oral antibiotics like cephalexin or nitrofurantoin are advisable. Normally a five day course of oral antibiotic will be sufficient for the treatment of uncomplicated UTI or asymptomatic bacteraemia in pregnant women. As the patient is currently at her 38 weeks of gestation nitrofurantoin is contraindicated so it is best to prescribe her with Oral Cephalexin. This is because nitrofurantoin is associated with an increased risk of neonatal jaundice and haemolytic anaemia, so should not be used close to delivery, that is after 37 weeks of gestation or sooner if early delivery is planned.
Acute pyelonephritis should be treated with Intravenous antibiotic treatment, guided by urine culture and sensitivity reports as soon a available. A course of minimum of 10-14 days with IV + oral antibiotics is recommended as treatment for pyelonephritis, along with an increased fluid intake as intravenous fluids in clinically dehydrated patients. Even though urinary alkalisers are safe in pregnancy, prescription of urinary alkalisers alone is not recommended due to its low effectiveness compared to antibiotics, also as it can result in a loss of treatment efficacy urinary alkalisers should never be used in combination with nitrofurantoin.
At any stage of pregnancy, if Streptococcus agalactiae, a group B streptococcus [GBS], is detected in urine the intrapartum prophylaxis for GBS is usually indicated.
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This question is part of the following fields:
- Obstetrics
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Question 54
Incorrect
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Question 55
Correct
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According to the RCOG Green-top guidelines on prevention and management of post-partum haemorrhage (PPH) which of the following statements is true?
Your Answer: For women delivering by caesarean section, Oxytocin 5 iu by slow IV injection should be used
Explanation:Misoprostol is not as effective as oxytocin but may be used if Oxytocin is not available e.g. home birth Recommended doses of Oxytocin For vaginal deliveries: 5 iu or 10 iu by intramuscular injection. For C-section: 5 iu by IV injection
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This question is part of the following fields:
- Clinical Management
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Question 56
Correct
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A 30-year-old woman comes in with her husband, complaining of difficulty conceiving after 18 months of regular sexual activity. She inquires about the possible outcomes for the treatment of various aetiologies during the discussion on aetiology, further work-up, and treatment.
Which of the following conditions has the best chance of being treated?Your Answer: Polycystic ovarian syndrome
Explanation:Treatment for infertility caused by ovulation issues has had the best results by far. PCOS, also known as Stein-Leventhal syndrome, is marked by hyperandrogenism, tiny cysts in the ovaries, acne, and hirsutism, as well as ovulation issues that result in anovulatory cycles due to hormonal imbalance.
70% of females with anovulatory periods begin ovulation under medical supervision, and 50% of those conceive within 6 to 9 months.
Infertility can be caused by low or no sperm counts, poor sperm motility, or dysmorphic sperms. Treatment options include fertility medicines that promote sperm production, artificial insemination with donor sperm, and intracytoplasmic injection of sperm, but success rates are poor (less than 25 percent ). Following pelvic inflammatory disease, previous surgery, or tuberculosis, the Fallopian tubes become obstructed or damaged, preventing sperm from reaching the ovum. Tubal blockages and adhesions are treated by laparoscopic surgery. The success rate of conception varies greatly depending on the degree of the blockage, ranging from 10% to 70%.
Turner syndrome is linked to infertility and ovarian dysgenesis. Treatment for gonadal dysgenesis and reversal of infertility is not an option. Because of the high likelihood of miscarriages, even after egg donation, the success rate is relatively low.
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This question is part of the following fields:
- Gynaecology
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Question 57
Correct
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Which of the following would normally be expected to increase during pregnancy:
Your Answer: Thyroxin-binding globulin
Explanation:Thyroid function in pregnancy is altered in two ways; the circulating levels of the thyroid binding proteins are increased, resulting in an increase in the total circulating levels of thyroid hormones (but a slight fall in the free component).
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This question is part of the following fields:
- Physiology
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Question 58
Incorrect
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A pregnant patient who is needle phobic has her nuchal translucency (NT) scan but refuses serum markers. You advise her the False Positive Rate of the scan is 5%. What would you advise the mother regarding the detection rate of Down Syndrome using NT alone?
Your Answer: 40%
Correct Answer: 70%
Explanation:The nuchal lucency measurement is the measure of the nuchal pad thickness. Children with down syndrome have an increased thickness of the nuchal pad. The risk of down’s syndrome increases with maternal age. The nuchal lucency test has an accuracy rate of 70%.
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This question is part of the following fields:
- Genetics
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Question 59
Incorrect
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Among the below given options, which is NOT associated with an increased risk for preeclampsia?
Your Answer: Prolonged intervals between pregnancies
Correct Answer: Age between 18 and 40 years
Explanation:Any new onset of hypertension associated with proteinuria after 20 weeks of gestation in a previously normotensive woman is referred to as Preeclampsia.
Most commonly found risk factors for pre-eclampsia are:
– Preeclampsia in a previous pregnancy
– Family history of preeclampsia
– a prior pregnancy with poor outcome like placental abruption, IUGR, fetal death in utero, etc
– An interdelivery interval greater than 10 years
– Nulliparity, increases risk by 8 times
– Pre-existing chronic medical conditions or chronic hypertension
– pre-existing or gestational Diabetes
– chronic Renal disease
– Thrombophilias g. protein C and S deficiency, antithrombin Ill deficiency, or Factor V Leiden mutation
– Antiphospholipid syndrome
– Systemic lupus erythematous
– Maternal age greater than or equal to 40 years
– Body Mass Index (BMI) greater than 30 kg/m2
– Multiple pregnancy
– Raised blood pressure at booking
– Gestational trophoblastic disease
– Fetal triploidyMaternal age between 18 and 40 years is found to be associated with a decreased risk for developing preeclampsia, and not an increased risk.
NOTE– Previously, age 16 years or younger was thought to be a risk factor for developing preeclampsia; however, recent studies conducted had failed to establish any meaningful relationship between the two. -
This question is part of the following fields:
- Obstetrics
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Question 60
Incorrect
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An HIV positive woman who is 18 weeks pregnant complains of frothy yellow vaginal discharge and vaginal soreness. A wet mount and microscopy confirms a Trichomonas vaginalis infection. Which of the following is the most appropriate treatment regime?
Your Answer: Metronidazole 2g orally single dose
Correct Answer: Metronidazole 500mg BD 7 days
Explanation:Trichomoniasis is considered a sexually transmitted infection found both in men and women 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. 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 for a HIV positive woman who is pregnant is 500mg of metronidazole twice daily for 7 days. High dose metronidazole as a 2g single dose tablet is not advised during pregnancy. All sexual partners should also be treated, and screening for other STIs should be carried out.
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This question is part of the following fields:
- Clinical Management
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Question 61
Incorrect
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Question 62
Correct
-
Regarding the foetus, which one of the following statements is true?
Your Answer: Fetal lie describes the long axis of the foetus to the long axis of the mother
Explanation:Fetal lie describes the relationship of the long axis of the foetus with respect to the long axis of the mother.
Coronal suture is the transverse suture separating the parietal bone from the frontal bone.
Umbilical cord is composed of two arteries and one vein. the vein carries the oxygenated blood, whereas the arteries contain the deoxygenated blood.
At the time of birth, the anterior fontanelle is open and appears as a soft jelly like structure. -
This question is part of the following fields:
- Anatomy
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Question 63
Incorrect
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Regarding pelvic inflammatory disease, which of the following is the tubal factor infertility rate?
Your Answer: 50%
Correct Answer: 12.50%
Explanation:Pelvic inflammatory disease (PID) is a known risk factor in causing tubal infertility due to its role in tubal damage. The tubal infertility rate after one episode of PID is thought to be about 12.5%. After two episodes the risk increases to 25%, and 50% after three episodes. The usual causative agents are chlamydia and gonorrhoea.
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This question is part of the following fields:
- Clinical Management
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Question 64
Correct
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Question 65
Correct
-
A patient is about to undergo an elective C-section. She wants to know how long it will take for her wound to completely heal.
How much time does it take for healing by primary intention to reach full tensile strength?Your Answer: 12 weeks
Explanation:Wound healing typically undergoes different stages that include haemostasis, inflammation, proliferation and remodelling. The phases are often shortened when healing occurs by primary intention such as in a surgical wound. Remodelling, which is the major strengthening phase, takes about 3 weeks, while it takes a total of 12 weeks to reach maximum tensile strength.
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This question is part of the following fields:
- Physiology
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Question 66
Correct
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During wound healing collagen alignment along tension lines is part of which phase?
Your Answer: Remodelling
Explanation:Realignment of collagen is part of the remodelling phase. Remodelling is usually underway by week 3. Maximum tensile wound strength is typically achieved by week 12.
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This question is part of the following fields:
- Physiology
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Question 67
Correct
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A 25-year-old woman at 39 weeks of gestation complaints of intermittent watery vaginal discharge, which has started last night after she had sex with her husband.
Speculum examination shows, pooling of straw-colored fluid in the posterior vaginal fornix. The cervical os is closed and there is leaking of liquor from cervical os when she is asked to cough or strain.
Which among the following best explains these clinical findings?Your Answer: Premature rupture of membranes (PROM)
Explanation:Presentation in the given case is classic for premature rupture of membranes (PROM) which was probably caused due to trauma during intercourse.
Premature rupture of membrane (PROM) is defined as the rupture of embryonic membranes before the onset of labor, regardless of the age of pregnancy. If occured before 37 weeks of gestation, it is termed as preterm PROM (PPROM.)A sudden gush of watery fluid per vagina is the classic presentation of rupture of the membranes (ROM), regardless of gestational age, however nowadays many women presents with continuous or intermittent leakage of fluid or a sensation of wetness within the vagina or on the perineum. Presence of liquor flowing from the cervical os or its pooling in the posterior vaginal fornix are considered as the pathognomonic symptom of ROM. Assessment of fetal well-being, the position of the fetus, placental location, estimated fetal weight and presence of any anomalies in PROM and PPROM are done with ultrasonographic studies.
Retained semen will not result in the findings mentioned in this clinical scenario as it have a different appearance.
Infections will not be a cause for this presentation as it will be associated with characteristic features like purulent cervical discharge, malodorous vaginal discharge, etc. Pooling of clear fluid in the posterior fornix is pathognomonic for ROM.
Urine leakage is common during the pregnancy, but it is not similar to the clinical scenario mentioned above.
Absence of findings like cervical dilation and bulging membranes on speculum exam makes cervical insufficiency an unlikely diagnosis in this case.
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This question is part of the following fields:
- Obstetrics
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Question 68
Incorrect
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A 31-year-old woman's blood results after having secondary amenorrhoea that lasted for 6 months are: Testosterone = 3.4 nmol/L (<1.6), Oestradiol = 144 pmol/L (100-500), LH = 12 U/L and FSH = 4 U/L. What sign or symptom is she likely to have?
Your Answer: Hirsutism
Correct Answer:
Explanation:Biochemical features suggest that this patient has polycystic ovary syndrome (PCOS). It is associated with signs and symptoms of hyperandrogenism (oligomenorrhea, irregular menstruation, hirsutism, hair loss, and acne) and elevated testosterone. PCOS patients are often overweight or obese, have insulin resistance (treated with Metformin) and an adverse risk profile for cardiovascular disease.
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This question is part of the following fields:
- Gynaecology
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Question 69
Correct
-
During pregnancy which one of the following laboratory parameters is decreased?
Your Answer: Platelet count
Explanation:In pregnancy, although it is a hypercoagulable state with an increase in clotting factors, the platelet count is decreased. Fibrinogen and erythrocyte sedimentation rate (ESR) may be both increased.
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This question is part of the following fields:
- Clinical Management
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Question 70
Incorrect
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A patient is seen in the gynaecology outpatient clinic and is noted to have large volume genital warts perianally and near the urethral meatus. You discuss treatment options and the patient opts for LASER therapy. Which of the following is the most appropriate type of LASER to use?
Your Answer: Diode
Correct Answer: CO2
Explanation:Vulval intraepithelial neoplasia is a premalignant condition which is associated with HPV or lichen sclerosis. Biopsy is essential for diagnosis. Treatment depends of the patients choice and include surgical excision of the area or laser therapy with CO2. Other treatment modalities include immunomodulating creams.
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This question is part of the following fields:
- Biophysics
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Question 71
Correct
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Which one of the following has the most significant effect on slowing drug metabolism in pregnancy?
Your Answer: Progesterone effect on gastric motility
Explanation:Progesterone down regulates gastric motility meaning drugs are absorbed and metabolised more slowly, thus drugs are absorbed, metabolised and cleared more slowly. Most of the drugs are transported after binding to the albumin.
Lower albumin levels mean a greater unbound drug fraction but as this may be thought to increase drug concentrations it actually leaves more available for hepatic clearance or renal excretion so overall drug concentrations are unchanged and metabolism increased.
Increase in hepatic flow will increase the metabolism of the drug as the drug will be transported faster.
Increased renal blood flow will result in the faster clearance of the drug from the body. -
This question is part of the following fields:
- Clinical Management
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Question 72
Correct
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Which ONE among the following factors does not increase the risk for developing postpartum endometritis?
Your Answer: Advanced maternal age
Explanation:The most common clinical findings in a postpartum women with endometritis are postpartum fever, with tachycardia relative to the rise in temperature, midline lower abdominal pain and uterine tenderness from the 2nd to 10th day of postpartum.
Most common risk factors for the development of postpartum endometritis are:
– Cesarean deliveries are considered as the most important risk factor for postpartum endometritis, especially those performed after the onset of labour.
– Young maternal age.
– Multiple digital cervical examinations.
– Prolonged rupture of membranes.
– Retention of placental products.
– Prolonged labour.
– Chorioamnionitis.
Advanced maternal age is not considered as a risk factor for development of postpartum endometritis. -
This question is part of the following fields:
- Obstetrics
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Question 73
Incorrect
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You are asked to speak to a 27 year old patient who is pregnant for the first time. She is concerned as her friend recently gave birth and the baby was found to have profound hearing loss. Her friend was told this was due to an infection whilst she was pregnant. What is the most common infective cause of congenital hearing loss?
Your Answer: Rubella
Correct Answer: Cytomegalovirus
Explanation:CMV is the most common congenital infection causing sensorineural deafness.
10-15% of infected infants will be symptomatic at birth. A further 10-15% who are asymptomatic at birth will develop symptoms later in life. Transmission can also be via breastmilk and the incubation period for CMV is 3-12 weeks. Diagnosis of fetal CMV infection is via amniocentesis however this should not be performed for at least 6 weeks after maternal infection and not until the 21st week of gestation -
This question is part of the following fields:
- Microbiology
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Question 74
Incorrect
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A 40 year old women who is 13 weeks pregnant is found to have be high risk for Downs following the combined screening test. What is the most appropriate further test to see if the foetus is affected?
Your Answer: Amniocentesis
Correct Answer: Chorionic Villous Sampling
Explanation:Chorion villus sampling is an invasive procedure which aims to collect the rapidly dividing cells in the placenta. It is used for numerous reasons including detection of early pregnancy, viability of the foetus, singleton pregnancy, confirm gestation age and for prenatal diagnosis of the fetal chromosomal abnormalities including diagnosis of Down’s syndrome. However it hold a 2% chance of miscarriage during the procedure. Nuchal thickness and imaging are part of the combined test that must have been performed before.
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This question is part of the following fields:
- Genetics
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Question 75
Correct
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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: 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 76
Incorrect
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A 46 year old women with a BMI of 34 is seen in clinic following hysteroscopy and biopsy for irregular menstrual bleeding. Histology shows hyperplasia without atypia. Following a discussion the patient declines any treatment but agrees she will try and lose weight. What is the risk of progression to endometrial cancer over 20 years?
Your Answer: 35-45%
Correct Answer:
Explanation:The risk of developing endometrial carcinoma is less than 5% over 20 years if the endometrium shows hyperplasia without atypia.
There are 2 types of Endometrial Hyperplasia:
1. Hyperplasia without atypia*
2. Atypical hyperplasiaMajor Risk Factors:
Oestrogen (HRT)
Tamoxifen
PCOS
Obesity
Immunosuppression (transplant) -
This question is part of the following fields:
- Clinical Management
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Question 77
Correct
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Syphilis is caused by which one of the following organisms?
Your Answer: Treponema Pallidum
Explanation:Syphilis is a sexually transmitted disease which is caused by spirochete called treponema pallidum. It can be divided into three stages. i.e. primary, secondary and tertiary syphilis.
– Primary syphilis is characterized by chancre formation at the site of sexual contact.
– Secondary syphilis ranges from maculopapular lesions to scaly lesions, inguinal lymphadenopathy, condylomata lata and split papules at the corner of mouth.
– Tertiary syphilis is the late stage of syphilis which is characterized by gummas formation and general paresis along with signs and symptoms of visceral involvement. -
This question is part of the following fields:
- Clinical Management
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Question 78
Correct
-
What is the average lifespan of a basophil (white blood cell)?
Your Answer: 3-4 days
Explanation:Basophils are granulocytic white blood cells. They express IgE antibody on their surface and react to release prostaglandins and leukotrienes to mediate an inflammatory, allergic reaction.
Blood Cell Lifespans:
Red Blood Cells 120 days
Platelets 5-9 days
White blood cells 2-5 daysNeutrophils (up to 5 days)
Basophils (2 to 3 days)
Eosinophils (2 to 5 days)
Monocytes (1 to 5 days)
Lymphocytes (variable) -
This question is part of the following fields:
- Physiology
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Question 79
Incorrect
-
A 40-year-old nulligravid woman comes to the office due to persistent abnormal uterine bleeding. Patient’s menstrual periods previously occurred monthly, which lasts of 4 days with moderate bleeding and light cramping. However, for the past 8 months, she has had intermenstrual spotting and bleeding which have occurred at varying intervals and last for 3-7 days.
Patient had started combination oral contraceptives 4 months ago, which has not improved the bleeding pattern.
On examination her temperature is 37.2 C (99 F), blood pressure is 126/76 mm Hg, pulse is 86/min and BMI is 29 kg/m2.
Speculum examination shows dark red blood in the posterior vaginal vault but no cervical or vaginal lesions. Remainder of the pelvic examination was normal.
Her laboratory results are as follows:
- Hemoglobin: 12.2 g/dL
- Prolactin: 5 ng/mL
- TSH: 1.8 µU/mL
- Urine pregnancy test is negative.
Pelvic ultrasound shows an anteverted uterus without any adnexal masses.
Which of the following is considered the best next step in management of this patient?Your Answer: Progesterone withdrawal test
Correct Answer: Endometrial biopsy
Explanation:Uncontrolled endometrial proliferation due to excess and unregulated estrogen is the reason for intermenstrual bleeding and irregular menses along with abnormal uterine bleeding (AUB) in this patient. The condition is mostly associated with an increased risk of endometrial hyperplasia
ancer.
The absolute risk of endometrial hyperplasia
ancer is very low in women aged <45, therefore they can be started on combination medication with estrogen/progestin contraception (ie, medical management) without the evaluation of endometrium. The estrogen component of medication regulates the menstrual cycle by build up the endometrium; whereas the progestin component helps in shedding of the endometrium.
However, patients who have continued irregular menstrual bleeding even while on combination contraceptives require further evaluation as they have failed to improve with medical management. In such patients, the endometrial lining will be too thick for the progestin to completely shed during menstruation and this unshed endometrium continues to undergo dysregulated proliferation, leading to an increased risk of endometrial hyperplasia
ancer. Therefore, patients age below 45 with AUB who have failed medical management require an endometrial biopsy.
AUB persistent above 6 months, obesity, and/or tamoxifen therapy are the other indications for endometrial biopsy in women age <45, as all of these will increase the amount of unopposed endometrial estrogen exposure. In patients with heavy menstrual bleeding and anemia, coagulation studies are performed to evaluate for bleeding disorders like von Willebrand disease. It is not necessary in this patient as she have a normal hemoglobin level. In patients with heavy, but regular (ovulatory) bleeding an endometrial ablation, which is a procedure used to remove the excess endometrium, can be considered as the treatment option. Endometrial ablation is contraindicated in undiagnosed cases of AUB as it prevents evaluation of the endometrium in patients with possible endometrial hyperplasia
ancer.To check for abnormalities of the uterus like didelphys or of the Fallopian tube like scarring, a hysterosalpingogram is used but it is not useful to evaluate AUB. In addition, as the procedure could spread cancerous endometrial cells into the abdominal cavity, hysterosalpingogram is contraindicated in cases of undiagnosed AUB.
To evaluate secondary amenorrhea, ie. absence of menses for >6 months in a patient with previously irregular menses, a progesterone withdrawal test is used to determine whether amenorrhea is from low estrogen level, in negative cases there will be no bleeding after progesterone. This test is not indicated or relevant in this case as patient had continued bleeding while on oral contraceptives suggestive of high estrogen levels.
Evaluation for endometrial hyperplasia
ancer with an endometrial biopsy is required for those women age <45 with abnormal uterine bleeding who have failed medical management with oral contraceptives. -
This question is part of the following fields:
- Obstetrics
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Question 80
Incorrect
-
Luteal phase deficiency is characterised by:
Your Answer: Associated with delayed menstruation
Correct Answer: Has inadequate luteal progesterone production
Explanation:Luteal phase occurs after the ovulation. Luteal defect means that the luteal phase is shorter than 10 days and women will find it difficult to sustain the pregnancy. There is decreased progesterone, LH and FSH production in this case.
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This question is part of the following fields:
- Physiology
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Question 81
Incorrect
-
A 27-year-old woman presents for difficulty and pain in attempting sexual intercourse. She states that she never had such symptoms prior. The pain is not felt at the time of penetration, but appears to hurt deeper in the vagina.
She was recently pregnant with her first child and delivery was three months ago. She did not have an episiotomy or sustain any vaginal lacerations during delivery. She denies any vaginal bleeding since her lochia had stopped two months ago. She is still breastfeeding her child.
Which of the following is the most likely cause of her dyspareunia?Your Answer: Unrecognised mid-vaginal laceration.
Correct Answer: Atrophic vaginal epithelium.
Explanation:This is a patient that recently gave birth and is still breastfeeding presenting with dyspareunia. The most likely cause would be a thin atrophic vaginal epithelium. This is very common presentation and is due to the low oestrogen levels due to the prolactin elevation from breastfeeding.
An unrecognised and unsutured vaginal tear should have healed by this time and should not be causing issues.
Endometriosis tends to resolve during a pregnancy, but if this was the issue, it would have caused dyspareunia prior to pregnancy.
Vaginal infective causes of dyspareunia, such as monilial or trichomonal infections, are rare in amenorrhoeic women.
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This question is part of the following fields:
- Obstetrics
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Question 82
Incorrect
-
A 22 year old woman miscarries at 6 weeks gestation. At checkup, she shows no obvious signs of complication. What would you advise regarding further pregnancy testing?
Your Answer: Urine pregnancy test in 2 weeks
Correct Answer: Urine pregnancy test in 3 weeks
Explanation:In the management of a miscarriage, after the completion of 7-14 days of expectant management, the woman is advised to take a pregnancy test after 3 weeks. In case of a positive result she is to return for further care.
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This question is part of the following fields:
- Biochemistry
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Question 83
Incorrect
-
A 50-year-old menopausal woman complained of regular hot flushes that interfered with her sleep and job. She had a ten-year history of oestrogen-dependent breast cancer.
What is the most effective treatment for her symptoms?Your Answer: Progesterone only
Correct Answer: Paroxetine
Explanation:Paroxetine is an SSRI used for hot flushes in women with contraindication for hormonal therapy.
Hormonal or other pharmacotherapy is usually needed for women with bothersome hot flashes. For most women with moderate to very severe hot flashes and no contraindications, we suggest MHT. Women with an intact uterus need both oestrogen and a progestin, while those who have undergone hysterectomy can receive oestrogen only. For women interested in MHT, the first step is to determine the potential risks for the specific individual.
The majority of perimenopausal and recently menopausal women are good candidates for short-term hormone therapy for symptom relief. However, for women with a history of breast cancer, coronary heart disease (CHD), a previous venous thromboembolic event (VTE) or stroke, or those at moderate or high risk for these complications, alternatives to hormone therapy should be suggested. For women with moderate to severe hot flashes who are not candidates for hormone therapy based upon their breast cancer, CHD, or VTE risk and for those who choose not to take MHT, we suggest nonhormonal agents. The agents most commonly used include SSRIs, serotonin-norepinephrine reuptake inhibitors (SNRIs), antiepileptics, and centrally acting drugs.
Black Cohosh is found to be no more significant than placebo.
Long-term use of mefenamic acid is controversial and not recommended. -
This question is part of the following fields:
- Gynaecology
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Question 84
Correct
-
What is the most common Type II congenital thrombophilia?
Your Answer: Factor V Leiden mutation
Explanation:Factor V Leiden is the most common congenital thrombophilia. Named after the Dutch city Leiden where it was first discovered. Protein C and S deficiencies are type 1 (Not type 2) thrombophilias Antiphospholipid syndrome is an acquired (NOT congenital) thrombophilia
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This question is part of the following fields:
- Clinical Management
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Question 85
Incorrect
-
Evidence from a panel of experts is what level of evidence
Your Answer: III
Correct Answer: IV
Explanation:Level I: Evidence obtained from at least one properly designed randomized controlled trial. Level II-1: Evidence obtained from well-designed controlled trials without randomization. Level II-2: Evidence obtained from well-designed cohort or case-control analytic studies, preferably from more than one centre or research group. Level II-3: Evidence obtained from multiple time series designs with or without the intervention. Dramatic results in uncontrolled trials might also be regarded as this type of evidence. Level III: Opinions of respected authorities, based on clinical experience, descriptive studies, or reports of expert committees.
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This question is part of the following fields:
- Epidemiology
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Question 86
Correct
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A 32-year-old woman at 33 weeks of gestation presents with vaginal bleeding.
A pelvic ultrasound was done, which confirms the diagnosis of placenta praevia and you are planning a cesarean section as it is the most appropriate mode of delivery.
Which among the following is considered a possible outcome of cesarean section delivery?Your Answer: Increase risk of adhesions
Explanation:Obstetric complications during or following a cesarean section delivery include:
-Increased risk of maternal mortality.
-Increased need for cesarean sections in the subsequent pregnancies.
-Increased risk for damage to adjacent visceral organs especially bowels and bladder.
-Increased risk of infections.Increased risk for formation of adhesions is a complication after cesarean section and this is the correct response for the given question.
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This question is part of the following fields:
- Obstetrics
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Question 87
Incorrect
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Which of the following causes of polyhydramnios is more common?
Your Answer: Twin pregnancy
Correct Answer: Idiopathic
Explanation:Maternal disorders, such as diabetes, in-utero infections, drug usage, placental abnormalities and fetal conditions as congenital and chromosomal abnormalities, Rh iso-immunization, and multiple gestations, are generally associated with polyhydramnios. Congenital abnormalities such as duodenal, oesophageal, or intestinal atresia of the foetus are the most common malformations that typically cause gastro-intestinal obstruction and interfere with fetal swallowing and/or absorption resulting with polyhydramnios. However, in about 70% of cases, none of the aforementioned aetiologies are causes of polyhydramnios, and it is referred to as idiopathic or isolated.
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This question is part of the following fields:
- Physiology
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Question 88
Correct
-
HPV genotypes 6 and 11 are associated with which of the following?
Your Answer: Low grade squamous intraepithelial lesions of the cervix (LSIL)
Explanation:HPV types 6 and 11 are associated with low risk, low grade squamous intraepithelial lesion. While types 16,18,31 and 33 are associated with high risk, high grade neoplasia.
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This question is part of the following fields:
- Microbiology
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Question 89
Incorrect
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After a vaginal delivery, a patient suffers a perineal tear. On examination the laceration involves the external anal sphincter and has partially torn the internal anal sphincter. Which of the following classifies this tear?
Your Answer: 3b
Correct Answer: 3c
Explanation:During childbearing the vagina and perineum are prone to lacerations that may involve the skin or can extend into the anal sphincter complex. It is important to be able to identify obstetric and anal sphincter injuries to provide adequate care and prevent complications. In the classification of obstetric tears according to RCOG guidelines:
First degree tear: injury to the perineal skin and/or the vaginal mucosa
Second degree tears: Injury to perineum involving perineal muscles but not the anal sphincter.
Third-degree tear: Injury to perineum involving the anal sphincter complex:
Grade 3a tear: Less than 50% of external anal sphincter (EAS) thickness torn.
Grade 3b tear: More than 50% of EAS thickness torn.
Grade 3c tear: Both EAS and internal anal sphincter (IAS) torn.
Fourth-degree tear: Injury to perineum involving the anal sphincter complex (EAS and IAS)
and anorectal mucosa. -
This question is part of the following fields:
- Anatomy
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Question 90
Incorrect
-
A 35 year old female presented with complaints of a 3 cm lump in her right breast, which was firm & irregular. O/E there was also some colour change over the breast. The most likely diagnosis would be?
Your Answer: Carcinoma
Correct Answer:
Explanation:Breast carcinoma is one of the most common malignancies in women. It presents as an irregular, firm consistency nodule/lump, which is attached to the skin most of the time. The overlying skin also exhibits a peau d’ orange appearance, along with dimpling. A sebaceous cyst is a small cystic swelling with no colour change and can occur anywhere over the skin. A lipoma is a benign tumour of fats which is soft in consistency.
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This question is part of the following fields:
- Gynaecology
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Question 91
Correct
-
Regarding heart rate in pregnancy which of the following statements is true?
Your Answer: Heart rate increases by 15 beats per minute
Explanation:The following cardiovascular changes occur during pregnancy:
– Blood volume slowly increases by 40-50%
– Heart rate rises by 15 beats/min above baseline
– Stroke volume increases by 25-30%
– Cardiac output increases by approximately 30-50%
– Systemic vascular resistance (SVR) decreases by 20-30%
– Diastolic blood pressure consequently decreases between 12 and 26 weeks but increases again to pre-pregnancy levels by 36 weeks.
As most of the changes occur in the first 12 weeks of gestation cardiac problems are likely to present in early pregnancy -
This question is part of the following fields:
- Physiology
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Question 92
Correct
-
The COCP (Combined Oral Contraceptive Pill) causes all of the following biochemical effects EXCEPT which one?
Your Answer: Elevate FSH
Explanation:Remember patients with PCOS have elevated LH. COCPs suppress synthesis and secretion of FSH and the mid-cycle surge of LH, thus inhibiting the development of ovarian follicles and ovulation COCPs reduce hyperandrogenism as reduced LH secretion results in decreased ovarian synthesis of androgens. Furthermore they stimulate the liver to produce Sex Hormone Binding Globulin which leads to decreased circulating free androgens. Other mechanisms include reduction in adrenal androgen secretion and inhibition of peripheral conversion of testosterone to dihydrotestosterone and binding of dihydrotestosterone to androgen receptors
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This question is part of the following fields:
- Clinical Management
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Question 93
Incorrect
-
A 29-year-old pregnant woman in her first trimester of pregnancy presented to the medical clinic for routine antenatal care. Upon interview and history taking, it revealed that she is positive for Hepatitis C virus antibody (HCVAb). She is now concerned about transmitting the virus to her baby.
Which of the following is considered correct about the patient's condition?Your Answer: Co-existence of HIV has no effect on HCV transmission
Correct Answer: Fetal scalp blood sampling should be avoided
Explanation:Invasive procedures as fetal scalp blood sampling or internal electrode and episiotomy increase vertical transmission of HCV, especially in patients with positive HCV RNA virus load at delivery that is why it should be avoided.
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This question is part of the following fields:
- Obstetrics
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Question 94
Correct
-
A 28 year old patient has a diagnosis of PCOS. She has been trying to conceive for 2 years. Her BMI is 26 kg/m2 and she is a non-smoker. She has been taking Clomiphene and metformin for the past 6 months. What is the next most appropriate treatment?
Your Answer: Gonadotrophins
Explanation:Management of PCOS includes OCP, cyclical oral progesterone, metformin, clomiphene (which is more effective in inducing ovulation than metformin) and life-style changes. In women who are tolerant to these therapies Gonadotrophins should be trialled. However lifestyle changes should be able to improve the condition significantly. Clomiphene shouldn’t be continued for more than 6 months.
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This question is part of the following fields:
- Clinical Management
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Question 95
Incorrect
-
A woman who underwent a lower (uterine) segment Caesarean section (LSCS) is informed that her placenta was retained and needed to be removed manually during the procedure. She is now experiencing intermittent vaginal bleeding with an oxygen saturation of 98%, a pulse of 84 bpm and a BP of 124/82mmHg. Her temperature is 37.8C. Which complication of C-section is the woman suffering from?
Your Answer: Retained POC
Correct Answer: Endometritis
Explanation:Endometritis is inflammation of the inner lining of the uterus (endometrium). Symptoms may include fever, lower abdominal pain, and abnormal vaginal bleeding or discharge. It is the most common cause of infection after childbirth. The intermittent vaginal bleeding and the requirement for manual removal of the placenta suggest endometritis as the most possible diagnosis.
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This question is part of the following fields:
- Obstetrics
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Question 96
Incorrect
-
You see a patient who is 32 weeks pregnant. She complains of tingling to the right buttock and shooting pain down the leg. You suspect Piriformis syndrome. Regarding Piriformis which of the following statements are true?
Your Answer: Main action is internal rotation of the hip
Correct Answer: Insertion is onto the greater trochanter
Explanation:The proximal attachment of the piriformis muscles is from the anterior surface of sacrum and it attaches distally to the superior border of the greater trochanter of the femur. It is innervated by the anterior rami of S1 and S2.
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This question is part of the following fields:
- Anatomy
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Question 97
Incorrect
-
Which of the following is known to increase the risk of endometrial cancer?
Your Answer: Coffee consumption
Correct Answer: PCOS
Explanation:The risk factors of endometrial cancer include obesity, diabetes, late menopause, unopposed oestrogen therapy, tamoxifen therapy, HRT and a family history of colorectal and ovarian carcinoma.
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This question is part of the following fields:
- Epidemiology
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Question 98
Correct
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Question 99
Incorrect
-
A 40-year-old woman who is at 34 weeks of pregnancy presented to the medical clinic for advice since her other two children were diagnosed with whooping cough just 8 weeks ago, she is worried for her newborn about the risk of developing whooping cough.
Which of the following is considered the most appropriate advice to give to the patient?Your Answer: Give Pertussis vaccine booster DPTa after delivery
Correct Answer: Give Pertussis vaccine booster DPTa now
Explanation:To help protect babies during this time when they are most vulnerable, women should get the tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis vaccine (Tdap) during each pregnancy.
Pregnant women should receive Tdap anytime during pregnancy if it is indicated for wound care or during a community pertussis outbreak.
If Tdap is administered earlier in pregnancy, it should not be repeated between 27 and 36 weeks gestation; only one dose is recommended during each pregnancy.Optimal timing is between 27 and 36 weeks gestation (preferably during the earlier part of this period) to maximize the maternal antibody response and passive antibody transfer to the infant.
Fewer babies will be hospitalized for and die from pertussis when Tdap is given during pregnancy rather than during the postpartum period. -
This question is part of the following fields:
- Obstetrics
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Question 100
Correct
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A 37-year-old woman visits a gynaecological clinic for a check-up. A cervical screening test is performed by the doctor. HPV Type Non-16/18 is detected in her cervical cytology. Squamous cells and other abnormalities were found to be absent in the reflex liquid-based cytology.
Which of the following is the most appropriate next step in this patient's care?Your Answer: Repeat Cervical screening test in 12 months
Explanation:A cervical screening test was performed on this patient, and the result revealed the presence of the Human Papilloma Virus Type non-16/18. Reflex liquid base cytology was conducted, but no further abnormalities were seen. In this case, the patient should be offered a 12-month repeat cervical screening cytology. If the patient’s repeated cervical screening cytology after 12 months revealed LSIL, she should be referred for a colposcopy.
If HPV is discovered at 12 months, regardless of the LBC result, some women may be at higher risk of having high-grade abnormalities and should be referred to colposcopy. These include:
– women 2 or more years overdue for screening at the time of the initial screen
– women who identify as being of Aboriginal or Torres Strait Islander
– women aged 50 years or older.Summary of recommended actions based on the level of risk
Intermediate danger:
– HPV non-16/18 positive, intermediate risk (with negative or low-grade cytology)
If feasible, repeat the HPV test after 12 months.
A three-to-six-month delay would be acceptable. Delays of longer than six months are discouraged.
Follow up HPV test – HPV non 16/18 (possible high grade cytology or high-grade squamous lesion (HSIL) – Treated as Higher risk.High-risk:
HPV non-16/18 positive on follow-up HPV test (with negative or low-grade cytology)
Refer to an expert right away for further investigation.If your patient is: 2 years or more past due for screening at the time of the initial screening, and identifies as Aboriginal or Torres Strait Islander aged 50 or older, they may be at higher risk and should be referred to a professional at once for additional evaluation.
HPV 16/18 positive with any of the following non–16/18 positive: a glandular anomaly in high-grade cytology high-grade squamous lesion (HSIL) cancer. Refer to an expert right away for further investigation.
Currently, several colposcopy facilities are experiencing strong demand and extended wait times. If you are concerned that your patient will be delayed, you should call the specialist or clinic to which your patient has been referred.
On the Cure Test Pathway, wherever possible, continue testing as planned. A woman who has been treated for HSIL (CIN2/3) should have a 12-month follow-up co-test and annual tests after that. She can resume standard 5-yearly screening after receiving two consecutive negative co-tests. -
This question is part of the following fields:
- Gynaecology
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Question 101
Correct
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Question 102
Correct
-
In normal physiological changes in pregnancy, all of the following are increased, EXCEPT:
Your Answer: Peripheral resistance
Explanation:The heart adapts to the increased cardiac demand that occurs during pregnancy in many ways:
Cardiac output increases throughout early pregnancy, and peaks in the third trimester, usually to 30-50% above baseline.
Oestrogen mediates this rise in cardiac output by increasing the pre-load and stroke volume, mainly via a higher overall blood volume (which increases by 40–50%).
The heart rate increases, but generally not above 100 beats/ minute.
Total systematic vascular resistance decreases by 20% secondary to the vasodilatory effect of progesterone. Overall, the systolic and diastolic blood pressure drops 10–15 mm Hg in the first trimester and then returns to the baseline in the second half of pregnancy.
All of these cardiovascular adaptations can lead to common complaints, such as palpitations, decreased exercise tolerance, and dizzinessA pregnant woman may experience an increase in the size of the kidneys and ureter due to the increased blood volume and vasculature.
Later in pregnancy, the woman might develop physiological hydronephrosis and hydroureteronephrosis, which are normal.
There is an increase in glomerular filtration rate associated with an increase in creatinine clearance, protein, albumin excretion, and urinary glucose excretion.
There is also an increase in sodium retention from the renal tube so oedema and water retention is a common sign in pregnant women -
This question is part of the following fields:
- Physiology
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Question 103
Correct
-
Regarding feto-maternal blood circulation, which of the following statements is false?
Your Answer: At term the placenta receives 70% of uterine blood flow
Explanation:The placenta is important for regulating feto-maternal blood circulation, ensuring that the two circulatory systems do not come into direct contact. The placenta receives 70-80% of the uterine blood flow into the decidual spiral arteries where nutrient, waste and gaseous exchange with fetal blood takes place via the villous core fetal vessels. Deoxygenated blood arrives at the placenta via two uterine arteries while oxygenated, nutrient-rich blood is circulated back to the foetus via a single umbilical vein. The pressure in the umbilical vein is about 20 mmHg.
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This question is part of the following fields:
- Embryology
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Question 104
Correct
-
During the menstrual cycle which hormone typically reaches its peak level on day 21 (assuming a 28 day cycle)?
Your Answer: Progesterone
Explanation:LH, FSH and Oestrogen have their peaks just before ovulation on day 14 whereas progesterone peaks around day 21.
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This question is part of the following fields:
- Endocrinology
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Question 105
Correct
-
A mother brought her 3-year-old daughter to the doctor with a complaint of vulval pruritus. On examination, the vulval region has a well-defined white plaque with a wrinkled surface and scattered telangiectasia. The diagnosis of lichen sclerosis was confirmed by histopathology.
Which of the following treatments is the most appropriate?Your Answer: Potent topical steroids
Explanation:Lichen sclerosis (LS) is a benign, chronic, progressive dermatologic condition characterized by marked inflammation, epithelial thinning, and distinctive dermal changes accompanied by symptoms of pruritus and pain.
Topical corticosteroids are the mainstay of therapy. Intralesional corticosteroid therapy is an additional option that is useful for the treatment of thick hypertrophic plaques that topical corticosteroids may not penetrate adequately.
Antibiotics or antifungals have no role in the treatment of LS since it’s not an infection.
Since histological diagnosis has already been made, there is no need to refer to dermatologist.
Surgical intervention is indicated for treatment of complications like adhesion and scarring. -
This question is part of the following fields:
- Gynaecology
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Question 106
Correct
-
A couple both in their late 20s come to you for a review as they have been trying to fall pregnant for the past 3 years.
She has a history of fallopian tube surgery following tubal obstruction which was diagnosed laparoscopically. During the surgery, there was evidence of mild endometriosis with uterosacral ligaments involvement. She has amenorrhea and galactorrhoea. On the other hand, his semen specimens have been persistently severely abnormal.
Which is the most appropriate management?Your Answer: They should use intracytoplasmic sperm injection (ICSI) in IVF,
Explanation:The most suitable treatment would be to use intracytoplasmic sperm injection (ICSI) in IVF. If hyperprolactinemia was the isolated underlying cause for the infertility, then treatment with a dopamine agonist would be suitable. However, since it is not the sole contributing factor, it is unlikely to be effective in this case. The same reasoning can be applied to the use of danazol to treat any remaining endometriosis.
Unfortunately, there is no treatment (including gonadotrophin injections) that would improve the severely abnormal semen specimen. The most appropriate option would be to use intracytoplasmic sperm injection (ICSI) with IVF. Through this method, any remaining tubal issues would be bypassed. Furthermore, it would be useful in mild endometriosis cases and would also treat the amenorrhea resulting from hyperprolactinemia. There is no justification to perform another laparoscopy to either check or treat endometriosis or any remaining tubal obstruction.
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This question is part of the following fields:
- Gynaecology
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Question 107
Incorrect
-
A 26-year-old woman came in with a two-year history of amenorrhea and excessive facial hair growth. She had previously given birth to two children. FSH, LH, Prolactin, and oestrogen levels in the blood are all normal. The amount of testosterone in the blood is somewhat higher.
More than 12 tiny cysts can be seen on a transvaginal pelvic ultrasonography.
Which of the following is the most likely diagnosis?Your Answer: Premature ovarian failure
Correct Answer: Polycystic ovarian syndrome
Explanation:This patient has experienced polycystic ovarian syndrome-like symptoms.
At least two out of three of the following criteria must be met to diagnose polycystic ovarian syndrome:
1- Hyperandrogenism suggesting an excess of androgens e.g. excess hair growth, acne etc.
2- Menstrual irregularities e.g. dysmenorrhea, oligomenorrhea, and amenorrhea.
3-The ovaries are polycystic if one ovary has 12 or more follicles or if the size of one or both ovaries has risen.Low FSH, LH, and pituitary hormones are typically associated with hypothalamic dysfunction, however this is not the case here.
Similarly, with premature ovarian failure, FSH/LH levels rise while oestrogen levels decrease.All of the other choices are incorrect.
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This question is part of the following fields:
- Gynaecology
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Question 108
Incorrect
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Prenatal screening is recommended if ultrasound scan at 16 weeks confirms that the foetus is male and the mother has had an affected son previously. Choose the single most likely condition from the following list of options. 7
Your Answer: Cystic fibrosis
Correct Answer: Duchene muscular dystrophy
Explanation:The condition should be an X-linked recessive condition, as it affects only male offspring. Duchene muscular dystrophy is an X-linked recessive condition. Cystic fibrosis is an autosomal recessive disorder. Spina bifida is a multifactorial condition. Down syndrome is caused by trisomy of chromosome 21. Spinal muscular atrophies are inherited in an autosomal-recessive pattern.
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This question is part of the following fields:
- Obstetrics
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Question 109
Correct
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Which vitamin deficiency leads to Wernicke's encephalopathy?
Your Answer: B1
Explanation:Vitamin B1 deficiency can lead to Wernicke’s encephalopathy. Alcoholics are at particular risk. In obstetrics all women with hyperemesis gravidarum should receive thiamine supplementation to prevent Wernicke’s.
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This question is part of the following fields:
- Clinical Management
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Question 110
Correct
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Which pharyngeal arch is closest to the head of the embryo?
Your Answer: 1st
Explanation:The arches are numbered according to their proximity to the head i.e. the 1st is the closest to the head end of the embryo and the 6th closest to the tail end as shown by the diagram below the table
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This question is part of the following fields:
- Embryology
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Question 111
Correct
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A 35-year-old female patient, gravida 1 para 1, visits the clinic to have her contraception method evaluated. The patient has had unpredictable bleeding for the past 8 months since receiving a subdermal progestin implant and begs that it be removed. She used to use combined oral contraceptives and would like to go back to it. The patient has primary hypertension, which she was diagnosed with last year and is effectively controlled on hydrochlorothiazide. She does not take any other medications or have any allergies. Her father and brother both suffer from type 2 diabetes. The patient does not smoke, drink, or use illegal drugs.
24 kg/m2 is her BMI. Blood pressure is 130/75 millimetres of mercury. Physical examinations are all normal. Which of the following is increased by using combination oral contraceptives?Your Answer: Worsening hypertension
Explanation:Overt hypertension, developing in about 5% of Pill users, and increases in blood pressure (but within normal limits) in many more is believed to be the result of changes in the renin-angiotensin-aldosterone system, particularly a consistent and marked increase in the plasma renin substrate concentrations. The mechanisms for the hypertensive response are unclear since normal women may demonstrate marked changes in the renin system. A failure of the kidneys to fully suppress renal renin secretion could thus be an important predisposing factor. These observations provide guidelines for the prescription of oral contraceptives. A baseline blood pressure measurement should be obtained, and blood pressure and weight should be followed at 2- or 3-month intervals during treatment. Oral contraceptive therapy should be contraindicated for individuals with a history of hypertension, renal disease, toxaemia, or fluid retention. A positive family history of hypertension, women for whom long-term therapy is indicated, and groups such as blacks, especially prone to hypertensive phenomena, are all relative contraindications for the Pill.
COCs do not increase the risk of developing breast and endometrial cancer, Type 2 DM or breast fibroadenoma.
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This question is part of the following fields:
- Gynaecology
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Question 112
Incorrect
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A 20 year old patient attends clinic for a medical abortion at 12 weeks gestation. She has no known drug allergies and her STI screen was negative. What drug should she be prescribed as antibiotic prophylaxis?
Your Answer: Azithromycin 1g PO stat dose
Correct Answer: Metronidazole 1g PR stat dose
Explanation:According to the Royal College of Obstetrics and Gynaecology guidelines for abortion care it advises dual antibiotic regimes for antibiotic prophylaxis.
Metronidazole 1g per rectum or 800 mg orally can be given before or at the time of the abortion in women who have tested negative for Chlamydia trachomatis infection.Alternatively, Doxycycline (100mg oral, twice daily for 7 days) or Azithromycin 1g stat doses should be given in addition to metronidazole to be effective against Chlamydia trachomatis anaerobes.
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This question is part of the following fields:
- Clinical Management
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Question 113
Correct
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A 26 year old patient with PCOS has been trying to conceive for 2 years. Her BMI is 26 kg/m2. She is a non-smoker. Which of the following is the most appropriate first line treatment?
Your Answer: Clomiphene
Explanation:Firstline medical management of PCOS is with clomiphene.
Ovulation Disorders
WHO Group I : Hypothalamic pituitary failure (Stress, anorexia, exercise induced)
Management:
Increase BMI if <19 kg/m2
Reduce exercise if high levels
Pulsatile GnRH or Gonadotrophins with LH activity to induce ovulationWHO Group II : Hypothalamic-pituitary-ovarian dysfunction (PCOS)
Management:
Weight reduction if BMI >30
Clomiphene/Clomiphene (1st line)
Metformin (1st line)
Clomiphene & Metformin (1st/2nd line)
Laparoscopic drilling (2nd line)
Gonadotrophins (2nd line)WHO Group III : Ovarian failure
Management:
Consider IVF with donor eggs -
This question is part of the following fields:
- Clinical Management
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Question 114
Incorrect
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A 33-year-old female presents with 3 months of irregular vaginal bleeding. Prior to this her menstrual periods were normal.
Which one of the following is the most appropriate initial laboratory test for this patient?Your Answer: LH and FSH
Correct Answer: hCG
Explanation:In women of childbearing age, the most likely cause of abnormal vaginal bleeding is pregnancy; thus, the most appropriate initial test would be an hCG level. Once pregnancy has been excluded, patient history would guide further testing. Iatrogenic causes, usually resulting from certain medicines or supplements, are the next most common cause in this age group, followed by systemic disorders. Haemoglobin and haematocrit would be appropriate only if the patient seemed acutely anaemic due to the abnormal bleeding.
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This question is part of the following fields:
- Gynaecology
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Question 115
Incorrect
-
Ulipristal is thought to prevent pregnancy by what primary mechanism?
Your Answer: Prevention of endometrial implantation via endometrial membrane alteration
Correct Answer: Inhibition of ovulation
Explanation:Ulipristal is a progesterone receptor modulator that is used up to 120 hours following unprotected intercourse. It inhibits ovulation. The dose is 30 mg.
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This question is part of the following fields:
- Clinical Management
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Question 116
Incorrect
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Maternal blood flow through the uterine artery at term is approximately
Your Answer: 300ml/min
Correct Answer: 750ml/min
Explanation:Uterine blood flow increases 40-fold to approximately 700 mL/min at term, with 80 per cent of the blood distributed to the intervillous spaces of the placentae, and 20 per cent to the uterine myometrium.
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This question is part of the following fields:
- Endocrinology
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Question 117
Correct
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A 30 year old patient attends for non-invasive pre-natal screening for Down's syndrome. You advise her that the result will take the form of a risk score and higher risk results will be offered CVS or amniocentesis. What is the cut-off figure between low and high risk?
Your Answer: 1 in 150
Explanation:1 in 150 is the cut off. Where pre-natal screening shows a risk of 1 in 150 or greater invasive testing is typically offered.
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This question is part of the following fields:
- Clinical Management
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Question 118
Incorrect
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At the 18th week of her pregnancy, a 32-year-old woman presents with a fishy-smelling, thin, white homogeneous, and offensive vaginal discharge. Under light microscopy, a sample of the discharge contains clue cells.
Which of the following assertions about this condition is correct?Your Answer: The condition is sexually transmitted disease
Correct Answer: There is a relapse rate of over 50% in 6 months
Explanation:Reported cure rates for an episode of acute BV vary but have been estimated to be between 70% and 80%. Unfortunately, more than 50% of BV cases will recur at least once within the following 12 months. Because the aetiology of BV is still not entirely understood, identifying the cause of recurrent cases is challenging. Reinfection may play a role in explaining recurrent BV, but
treatment failure is a more likely contributor. There are several theories that try to explain recurrence and persistent symptoms. The existence of a biofilm in the vagina is one such theory and is the subject of ongoing research. Biofilms occur when microorganisms adhere to surfaces. G vaginalis, one of the primary organismsBV is not a sexually transmitted infection. The antibiotic of choice to treat BV is Metronidazole. Reassurance is not acceptable as a means of treatment.
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This question is part of the following fields:
- Gynaecology
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Question 119
Correct
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During wound healing the clotting cascade is activated. Which of the following activates the extrinsic pathway?
Your Answer: Tissue Factor
Explanation:The extrinsic pathway is activated by the tissue factor, which converts factor VII to VIIa which later on converts factors X and II to their activated form finally leading to the conversion of fibrinogen to fibrin fibres.
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This question is part of the following fields:
- Physiology
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Question 120
Correct
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A 29-year-old nulliparous woman is admitted to the hospital at 37 weeks of gestation after losing about 200 mL of blood per vagina after having sexual intercourse. The bleeding has now ceased and her vitals are below:
Pulse rate: 64 beats/min
Blood pressure: 120/80 mmHg
Temperature: 36.8°C
On physical exam, the uterus is enlarged and is 37 cm above the pubic symphysis. The uterus is lax and non-tender. On ultrasound, the fetal presentation is cephalic with the head freely mobile above the pelvic brim. The fetal heart rate assessed by auscultation is 155 beats/min.
Which of the following is the most likely of bleeding in this patient?Your Answer: Placenta praevia.
Explanation:In this pregnant patient with an antepartum haemorrhage at 37 weeks of gestation, her clinical presentation points to a placenta previa. Her bleeding has stopped, the uterus is of the expected size and non-tender, and the fetal head is still mobile above the pelvic brim which are all findings that would be consistent with a placenta praevia. An ultrasound examination would be done to rule-out or diagnose the condition.
An Apt test on the blood is necessary to ensure that this is not fetal blood that would come from a ruptured vasa praevia. Although this diagnosis would be unlikely since the bleeding has stopped. If there was a vasa praevia, there would be fetal tachycardia or bradycardia, where a tachycardia is often seen first but then bradycardia takes over late as fetal exsanguination occurs.
In a placental abruption with concealment of blood loss, the uterus would be larger and some uterine tenderness would be found on exam.
A cervical polyp could bleed after sexual intercourse and a speculum examination would be done to exclude it. However, it would be unlikely for a cervical polyp to cause such a large amount of blood loss. A heavy show would also rarely have as heavy as a loss of 200mL.
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This question is part of the following fields:
- Obstetrics
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Question 121
Correct
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Which of the following drugs is most associated with coronary artery spasm?
Your Answer: Ergometrine
Explanation:Ergot alkaloids e.g. Ergometrine, produce marked and prolonged alpha receptor mediated vasoconstriction. Its overdose can cause ischemia and gangrene of the limbs and bowel. It also causes coronary artery spasm and has been used by cardiologist as a provocation test.
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This question is part of the following fields:
- Clinical Management
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Question 122
Correct
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During her first month on OCPs, a patient had minimal bleeding at mid cycle. What is the most appropriate management?
Your Answer: Continue pills as usual.
Explanation:Breakthrough bleeding, or spotting, refers to when vaginal bleeding occurs between menstrual cycles. It may look like light bleeding or brown discharge.
Spotting is the most common side effect of birth control pills. It happens because the body is adjusting to changing levels of hormones, and the uterus is adjusting to having a thinner lining.
Taking the pill as prescribed, usually every day and at the same time each day, can help prevent bleeding between periods.
All other options are incorrect as this is a common side effect and will resolve on its own.
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This question is part of the following fields:
- Gynaecology
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Question 123
Correct
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An 20-year-old woman presents to you 6 hours after she was raped on day-12 of her menses which usually lasts for 28 days. You have decided to give her Postinor-2 (levonorgestrel 0.75 mg) as a post-intercourse contraceptive. She is requesting information about any potential adverse effects as well as its efficacy.
Which of the following statements is correct?Your Answer: The treatment fails to prevent pregnancy in 2-3% of women treated.
Explanation:Postinor-2 (levonorgestrel 750pg) is only an emergency contraceptive and is not designed to be a regular form of contraception. If taken within 24 hours, it is estimated to be able to prevent up 97-98% of pregnancies and 58% if given between 48-72 hours post-unprotected intercourse. It can cause vaginal bleeding within a few days of its administration if it is given before day 8-10 of her menstrual cycle. However, if given mid-cycle, it typically doesn’t affect the timing of her next period unless conception occurs. Nausea and vomiting were common when high doses of OCP were used as a post-intercourse contraceptive. Nausea and vomiting still can occur with Postinor-2, but not up to 50% of women. There is currently no evidence to suggest that the levonorgestrel dose would cause a virilising effect on female foetuses.
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This question is part of the following fields:
- Gynaecology
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Question 124
Correct
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Question 125
Incorrect
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A 38-year-old woman presents to the gynaecologic clinic with a complaint of headache, irritability, insomnia, abdominal bloating, anxiety, and breast tenderness around 4 to 5 days before menstruation for the last 8 months. There's also a limitation on daily activities and she has to take a week off from work. The patient's symptoms are relieved with the onset of menstruation. She does not smoke or drink alcohol. There is no other significant past medical history.
Which of the following is the best treatment?Your Answer: Oral contraceptive pills
Correct Answer: Fluoxetine
Explanation:The signs and symptoms of premenstrual dysmorphic disorder are well-known in this patient. Fluoxetine is the greatest therapeutic option among the available options.
For severe symptoms, clomipramine and danazol can be used interchangeably.
Bromocriptine, like oral contraceptives and evening primrose, has no scientific evidence to support its use in this syndrome.
NSAIDs are helpful for painful symptoms, but they only address a limited number of them. -
This question is part of the following fields:
- Gynaecology
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Question 126
Correct
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A 28-year-old woman (gravida 3, para 2) is admitted to hospital at 33 weeks of gestation for an antepartum haemorrhage of 300mL. The bleeding has now stopped. She had a Papanicolaou (Pap) smear done five years ago which was normal. Vital signs are as follows:
Pulse: 76 beats/min
Blood pressure: 120/80 mmHg
Temperature: 36.8°C
Fetal heart rate: 144/min
On physical exam, the uterus is lax and nontender. The fundal height is 34 cm above the pubic symphysis and the presenting part is high and mobile.
Other than fetal monitoring with a cardiotocograph (CTG), which one of the following should be the immediate next step?Your Answer: Ultrasound examination of the uterus.
Explanation:This is a case of a pregnant patient having vaginal bleeding. Given the patient’s presentation, the most likely cause of this patient’s antepartum haemorrhage is placenta praevia. The haemorrhage is unlikely to be due to a vasa praevia because a loss of 300mL would usually cause fetal distress or death, neither of which has occurred. Cervical malignancy is also unlikely as it typically would not have bleeding of this magnitude. A possible diagnosis would be a small placental abruption as it would fit with the lack of uterine tenderness and normal uterine size.
For the immediate management of this patient, induction of labour is contraindicated before the placental site has been confirmed. Also, induction should not be performed when the gestation is only at 33 weeks, especially after an episode of a small antepartum haemorrhage. An ultrasound examination of the uterus is appropriate as it would define whether a placenta praevia is present and its grade. It would also show whether there is any evidence of an intrauterine clot associated with placental abruption from a normally situated placenta.
If a placenta praevia is diagnosed by ultrasound, a pelvic examination under anaesthesia may be a part of the subsequent care, if it is felt that vaginal delivery might be possible. Usually it would be possible if the placenta praevia is grade 1 or grade 2 anterior in type. However, pelvic exam at this stage is certainly not the next step in care, and is rarely used in current clinical care.
A Papanicolaou (Pap) smear will be necessary at some time in the near future, but would not be helpful in the care of this patient currently.
Immediate Caesarean section is not needed as the bleeding has stopped, the foetus is not in distress, and the gestation is only 33 weeks.
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This question is part of the following fields:
- Obstetrics
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Question 127
Incorrect
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A 62-year-old woman complains of urinary incontinence for the past 12 months after having four pregnancies before the age of 30. She has to wear a 'pad' inside her pants all of the time because of this condition. She isn't on any hormone replacement therapy at the moment. Which of the following signs indicates that the incontinence is most likely true stress incontinence?
Your Answer: She did not have any incontinence during her pregnancies.
Correct Answer: Only small quantities of urine ore lost each time she is incontinent.
Explanation:Only little volumes of urine are lost when her intra-abdominal pressure is elevated during coughing, laughing, jumping, and straining, which is the only symptom associated with real stress incontinence.
The other reactions are significantly more compatible with a detrusor instability diagnosis (also called urge incontinence).
If she had incontinence throughout pregnancy, it would have been stress in nature, which is what her current incontinence is. -
This question is part of the following fields:
- Gynaecology
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Question 128
Correct
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A 25-year-old gravida 1 para 0 woman, at her 36 weeks of gestation, is brought to the emergency department by her mother due to a seizure. Patient was sitting outside when she suddenly had a 2-minute seizure with loss of urinary continence and is still confused when she arrived at the emergency department. Her mother reports that the patient had severe anxiety and had been acting out for the past several days. Her only surgery was a splenectomy after a motor vehicle collision last year.
On physical examination patient's temperature is 37.7 C (99.9 F), blood pressure is 158/98 mm Hg, and pulse is 120/min. Patient seems agitated and diaphoretic with bilaterally dilated pupils.
On systemic examination:
Cranial nerves are intact, neck is supple and nontender.
Cardiopulmonary examination is normal.
The abdomen is gravid without any rebound or guarding and the uterus is nontender.
There is 2+ pitting pedal edema bilaterally. Sensations and strength are normal in the bilateral upper and lower extremities.
Laboratory results are as follows:
a) Complete blood count shows
- Hematocrit: 33%
- Platelets: 140,000/mm3
- Leukocytes: 13,000/mm3
b) Serum chemistry
- Sodium: 124 mmol/L
- Potassium: 3.4 mmol/L
- Chloride: 96 mmol/L
- Bicarbonate: 21 mmol/L
- Blood urea nitrogen: 6.43 umol/L
- Creatinine: 70.7 umol/L
- Glucose: 4.4 mmol/L
c) Urinalysis
- Protein: none
- Ketones: present
CT scan of the head is normal.
Which of the following is most likely the diagnosis in this patient?Your Answer: Amphetamine intoxication
Explanation:This patient at 36 weeks of gestation likely had a generalized tonic-clonic seizure. A new-onset seizures in pregnancy can be due to either due to eclampsia which is pregnancy-specific or due to other non-obstetric causes like meningitis, intracranial bleeding etc.
In pregnant and postpartum women eclampsia is the most common cause for seizures which is classically associated with preeclampsia, a new-onset hypertension at ≥20 weeks gestation, with proteinuria and/or signs of end-organ damage. Although this patient has hypertension, absence of proteinuria and the additional findings like agitation, dilated pupils, hyponatremia and normal head CT scan are suggestive of another etiology. Patients with eclampsia will show white matter edema in head CT scan.
Amphetamine intoxication, which causes overstimulation of the alpha-adrenergic receptors resulting in tachycardia, hypertension and occasional hyperthermia, might be the cause for this patient’s seizures. Some patients will also have diaphoresis and minimally reactive, dilated pupils and severe intoxication can lead to electrolyte abnormalities, including significant hyponatremia (possibly serotonin-mediated) and resultant seizure activity.
Confirmation of Amphetamine intoxication can be done by a urine drug testing. it is essential to distinguishing between eclampsia and other causes of seizure in this case, as it will help to determine whether or not there is need for an emergency delivery.Altered mental status and electrolyte abnormalities can be due to heat stroke, however, patients affected this way will have an elevated temperature of >40 C /104 F associated with hemodynamic instabilities like hypotension.
Hemolysis, elevated liver enzymes, and low platelet count (HELLP) syndrome is a hypertensive disorder of pregnancy which can result in seizures (ie, eclampsia), but this patient’s hematocrit level is normal without any hemolysis, also patients with HELLP syndrome typically presents with a platelet count <100,000/mm3. Seizures and altered mental status in patients with prior splenectomy can be due to pneumococcal meningitis however, such patients will present with high fever and nuchal rigidity, making this diagnosis less likely in the given case. Amphetamine intoxication can present with hypertension, agitation, diaphoresis, dilated pupils, and a generalized tonic-clonic seizure due to hyponatremia, which is most likely to be the case here.
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This question is part of the following fields:
- Obstetrics
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Question 129
Correct
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A 28-year-old primigravid woman at 18 weeks of gestation comes to office for a routine prenatal visit and anatomy ultrasound. Patient feels well generally and has no concerns, also has no chronic medical conditions, and her only daily medication is a prenatal vitamin. She is accompanied by her mother as her husband was unable to get off work.
Ultrasound shows a cephalic singleton fetus measuring at <10th percentile consistent with severe growth restriction. There are bilateral choroid plexus cysts, clenched fists, and a large ventricular septal defect. Amniotic fluid level is normal with a posterior and fundal placenta.
Which of the following statements is the most appropriate initial response by the physician?Your Answer: There are some things about your ultrasound that I need to discuss with you; is it okay to do that now?
Explanation:SPIKES protocol for delivering serious news to patients includes:
– Set the stage includes arranging for a private, comfortable setting space, introduce patient/family & team members, maintain eye contact & sit at the same level and schedule appropriate time interval & minimize space for interruptions.
– Perception: Use open-ended questions to assess the patient’s/family’s perception of the medical situation.
– Invitation: should ask patient/family how much information they would like to know and remain cognizant of their cultural, educational & religious issues.
– Knowledge:
Warn the patient/family that serious news is coming, Speak in simple & straightforward terms, stop & check whether they are understanding.
– Empathy: Express understanding & give support when responding to emotions
– Summary & strategy: Summarize & create follow-through plan, including end-of-life discussions if applicable.The ultrasound findings of severe growth restriction, bilateral choroid plexus cysts, clenched fists, and a large ventricular septal defect are consistent with trisomy 18, the second most common autosomal trisomy, which results in fetal loss or neonatal death in the majority of cases. In this case, the physician is to deliver a very serious news to the patient who is presenting for a routine visit, believing her pregnancy was normal. When serious news is unexpected, it is especially important to prepare the patient and determine how the patient would like to receive the results.
The physician is supposed to provide a comfortable setting and must ask patient’s permission to share the results. This allows the patient to respond with her preference and avoids making assumptions about whom, if anyone, she would like to be present with. For example, some patients may prefer to defer discussion of the results until a major support person (eg, husband, mother) is present. In addition to establish patient’s preferred setting, physician should determine how much information the patient would like to receive. Some patients will prefer a detailed medical information about diagnosis and prognosis, whereas others may prefer to have time to process the news emotionally and receive further information later. The SPIKES protocol (Setting the stage, Perception, Invitation, Knowledge, Empathy, and Summary/strategy) is a six-step model that can guide physicians in delivering serious news to patients.These statements do not allow the patient to choose how she receives the results and assume that she does not want her mother present.
This statement fails to prepare the patient for serious news and prematurely jumps to sharing results using technical, medical terminology that may be difficult for the patient to comprehend. This approach could also be upsetting to a patient undergoing a routine ultrasound who is not expecting anything abnormal.
This statement inappropriately determines when and with whom the patient should receive the results. Instead the patient should be asked how she prefers to receive the results.
While delivering unexpected, serious news, physicians should prepare the patient and determine how the patient prefers to receive the information.
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This question is part of the following fields:
- Obstetrics
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Question 130
Incorrect
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In early pregnancy at what gestation does the Embryonic pole become visible on transvaginal ultrasound?
Your Answer: 4 weeks + 3 days
Correct Answer: 5 weeks + 3 days
Explanation:The gestational sac can be visualized from as early as 4–5 weeks of gestation and the yolk sac at about 5 weeks (Figure 6.3). The embryo can be observed and measured at 5–6 weeks gestation.
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This question is part of the following fields:
- Biophysics
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Question 131
Incorrect
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The femoral triangle contains all of the following structures EXCEPT which one?
Your Answer: Deep inguinal lymph nodes
Correct Answer: Genital branch of the genitofemoral nerve
Explanation:The contents of the femoral triangles are femoral nerve, artery and the vein. Along with the femoral sheath and lymphatics.
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This question is part of the following fields:
- Anatomy
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Question 132
Correct
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Which species of candida is the most common cause of genital candida infection in pregnancy?
Your Answer: Candida albicans
Explanation:Vulvovaginal candidiasis is the most common genital infection and it is caused by candida albicans in 80-92% of the cases. Other non albicans species include C.tropicalis, C.glabrata, C.krusei and C.parapsilosis. 20% of women of childbearing age are asymptotic colonisers of Candida species as part of their normal vaginal flora. This increases to 40% in pregnancy.
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This question is part of the following fields:
- Clinical Management
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Question 133
Correct
-
A 30-year-old woman presents to the clinic.
She complains of a 6 week history of amenorrhoea and on diagnostic testing, has a positive pregnancy test.
On past medical history, it is noted that she had a multiload (Cu375°) intrauterine device inserted six months ago.
On physical examination, The strings of the device are not visibly protruding through the external os, as would be expected.
She is happy to proceed with the pregnancy, and asks what should be done next.
What is the best next step in her management?Your Answer: Ultrasound of the pelvis.
Explanation:The best next step is to order an ultrasound of the pelvis to locate the IUCD in the uterine cavity.
Once the device is located, appropriate advice can be given about the pregnancy proceeding.
Uterine sounding and hysteroscopy are contraindicated in the presence of a viable pregnancy due to risks of infection and abortion.
Pelvic X-ray is indicated if the device cannot be located during the pelvic ultrasound. It can show if the device is in the peritoneal cavity or has been expelled from the uterus. It should only be done after the pregnancy.
In cases where the device is in the peritoneal cavity, a laparoscopy is indicated for device removal.
Pregnancy termination is not indicated simply because of the presence of an intrauterine device (IUCD) in the uterus, unless other factors dictate that this is appropriate.
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This question is part of the following fields:
- Gynaecology
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Question 134
Incorrect
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A 27-year-old woman presents to her general practitioner because of secondary amenorrhoea since the last 12 months.
She has a history of primary infertility
Of the hormone assays listed in the options, identify the assay that would indicate pregnancy if its result is significantly elevated.Your Answer: Serum progesterone.
Correct Answer: Serum luteinising hormone {LH).
Explanation:The levels of oestradiol (E2), progesterone, and prolactin (PRL) are all elevated during early pregnancy. However these elevations cannot be solely relied on to determine if pregnancy has occurred since increased levels of these hormones can also occur in pathologic states in non-pregnant women or, in some cases, even during menstrual cycles.
The levels of follicle stimulating hormone (FSH) are suppressed in pregnancy because of the elevated E2 and progesterone levels.
The correct answer is elevated levels of luteinising hormone (LH). This is because the beta sub-units of LH and human chorionic gonadotrophin (hCG) are almost identical and therefore, hCG is measured as LH in almost all LH assays (correct answer).
The LH levels can be slightly raised in polycystic ovarian syndrome; however, it is unlikely that the levels would increase above 30 mIU/mL in this condition.
The mid-cycle levels of LH can go up to 100-150 mIU/mL. If the levels are more than 200 mlU/mL, it usually indicates pregnancy.
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This question is part of the following fields:
- Gynaecology
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Question 135
Correct
-
Which one will decrease the risk of acquiring uterine fibroids?
Your Answer: Smoking
Explanation:Risk factors of fibroids include early menarche, nulliparity, early exposure to oral contraceptives (one study showed 13-16 years old), diet rich in red meats and alcohol, vitamin D deficiency, hypertension, obesity, and/or history of sexual or physical abuse.
Smoking is associated with actual reduced risk due to an unknown mechanism.
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This question is part of the following fields:
- Gynaecology
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Question 136
Correct
-
A 34 year old patient who has just undergone a C-section delivery has lost almost 1 litre of blood. You suspect uterine atony as the likely cause, and have bimanually compressed the uterus. Which of the following pharmacological interventions should follow?
Your Answer: Syntocin 5u by slow intravenous injection
Explanation:In the management of postpartum haemorrhage, it is essential that the bleeding is first mechanically prevented, followed by the administration of oxytocic drugs, which cause the uterine smooth muscle to contract and clamping off bleeding sites in the endometrium. The drug of choice in the treatment protocol of PPH is 5 units of syntocin, a synthetic oxytocin uterotonic, by slow intravenous infusion. This is particularly suitable in the case of uterine atony. Other uterotonics, misoprostol, carboprost, ergometrine, can be used, but are not as effective in an emergency setting.
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This question is part of the following fields:
- Clinical Management
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Question 137
Incorrect
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Raised FSH levels are found in all of the following conditions, EXCEPT:
Your Answer: Peri-menopausal women who had a hysterectomy with bilateral salpingooophorectomy
Correct Answer: Women on combined oral contraceptive pills
Explanation:Oestrogen- and progesterone-containing oral contraceptives inhibit LH, which suppresses the FSH and LH levels, preventing follicular development and ovulation. Combined pills suppress FSH and LH throughout the cycle, inhibit endometrial proliferation, and produce a scanty cervical mucus.
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This question is part of the following fields:
- Endocrinology
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Question 138
Incorrect
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Regarding monozygotic twins, all of the following are correct, EXCEPT:
Your Answer: Is not related to induction of ovulation
Correct Answer: Has a constant incidence 1:600 births
Explanation:The incidence of monozygotic twins is constant worldwide (approximately 4 per 1000 births). Approximately two thirds of twins are dizygotic.
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This question is part of the following fields:
- Genetics
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Question 139
Correct
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What are the branches of the pudendal nerves in women?
Your Answer: Perineal, inferior anal and dorsal nerve of clitoris
Explanation:The pudendal nerve provides sensory and motor innervation to regions of the anus, the perineum, the labia and the clitoris in women. The nerve is formed from the ventral rami of the S2-S4 sacral spinal nerves. The nerve is paired, each innervating the left and the right side of the body. The nerve gives the following branches in females: the inferior anal nerve, the perineal nerve and the dorsal nerve of the clitoris.
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This question is part of the following fields:
- Anatomy
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Question 140
Incorrect
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When a 75-year-old lady laughs, sneezes, coughs, or lifts big weights, she leaks pee. She also claims that she has the urge to pass pee 10-12 times a day, and that she can't go to the restroom half of the time. She appears to have a harder time with urgency. Infections are not found in a urine test. Except for a residual amount of 125cc, an ultrasound scan of the bladder, ureter, and kidneys is inconclusive.
Which of the following treatment options is the best fit for her?Your Answer: Anticholinergic medications
Correct Answer: Bladder training
Explanation:This woman has mixed incontinence, which includes signs and symptoms of both stresses and urges incontinence. The urge, on the other hand, irritates her. Bladder training would be the most appropriate management approach to investigate first for women with urge incontinence as the most troublesome symptom. The objectives are:
– Using a bladder diary to establish a baseline
– Creating a voiding schedule
– Over a long period, gradually increase the voiding interval in increments of 2- 5 minutes, to void every 3 hours.
– Other important strategies to consider are lifestyle changes like reducing fluid intake, losing weight, and avoiding diuretics-producing foods and beverages (e.g., alcoholic beverages, caffeine, etc).When urge incontinence does not respond to physical or behavioural therapy, anticholinergics along with ongoing bladder training are an alternative. A 4- to 6-week trial is employed. At six months, risk and benefit are weighed to see if treatment should be continued for those who react. Patients should be informed about anticholinergic side effects such as dry mouth and constipation, as well as how to control them.
Anterior colporrhaphy is a treatment for cystocele that involves repairing the front vaginal wall. It can help people with urine incontinence. If you don’t have a cystocele, bladder neck suspension is the best option.
Retropubic bladder suspension is a more intrusive surgery for treating stress urinary incontinence in patients who haven’t responded to less invasive treatments like pelvic floor exercise.The most essential initial conservative therapy to explore for patients with real stress incontinence and mixed (both stress and urge) urine incontinence when stress incontinence is the more prominent symptom is pelvic floor muscle exercise (e.g. Kegel exercise). For urge incontinence, more difficult training can be applied.
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This question is part of the following fields:
- Gynaecology
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Question 141
Correct
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Your 64-year-old patient has come to you with a uterine prolapse complaint.
Which of the following ligaments plays the most critical role in uterine prolapse pathophysiology?Your Answer: Uterosacral ligament
Explanation:The uterus needs support in order to remain centered inside the pelvic cavity. The support it receives comes in two forms: dynamic and passive. The ligaments of the uterus have an important role in both.
Dynamic support is provided by the pelvic diaphragm through tonic contractions while standing and sitting and active contractions during moments of increased abdominal pressure, such as coughing or sneezing. During these moments, the ligaments of the uterus transmit the force of the diaphragm towards the organ itself, maintaining its position.
The ligaments are also crucial in providing passive support. By minimizing movement of the body and the cervix, they maintain the uterus in the typical anteverted and anteflexed position directly on top of the bladder. This provides a support for the uterus when the abdominal pressure increases.
Hence, even though the broad ligament, round ligament and ovarian ligament have some role in the suspension of the uterus, the uterosacral ligament plays the most significant role. It is also the ligament used for surgical suspension of POP.
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This question is part of the following fields:
- Gynaecology
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Question 142
Correct
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At what week in pregnancy is testing for gestational diabetes (GD) advised
Your Answer: As soon as possible after booking if past history of GD
Explanation:Gestational diabetes (GDM) occurs in 2–9 per cent of all pregnancies. Screening for diabetes in pregnancy can be justified to diagnose previously unrecognized cases of pre-existing diabetes and to identify a group of women who are at risk of developing NIDDM later in life. No single screening test has been shown to be perfect in terms of high sensitivity and specificity for gestational diabetes. Urinary glucose is unreliable, and most screening tests now rely on blood glucose estimation, with an oral glucose tolerance test commonly used. The aim of glucose control is to keep fasting levels between 3.5 and 5.5 mmol/L and postprandial levels 7.1 mmol/L, with insulin treatment usually indicated outside these ranges. The women should be tested as soon as possible after booking if there is a history of GD.
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This question is part of the following fields:
- Clinical Management
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Question 143
Correct
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A 34-year-old woman presents to your gynaecologic clinic with complaints of abdominal bloating, headaches, insomnia, mood swings, and reduced sexual desire. These symptoms usually get worse a few days before the onset of menstruation and get better with menstruation. Her past medical history is insignificant, she is non-alcoholic and is not taking any medicine.
The most likely diagnosis with such a presentation is?Your Answer: Premenstrual syndrome
Explanation:As the most likely diagnosis, this woman meets diagnostic criteria for premenstrual syndrome (PMS).
Affective and physical symptoms that begin one week before menstruation and end four days after menstrual flow begins are diagnostic criteria for premenstrual syndrome. The symptoms must be present for at least three menstrual cycles and must not occur during the preovulatory period.
It’s critical to note that these symptoms are not caused by any medical or psychological condition, medications, drugs, or alcohol.Premenstrual dysphoric disorder is a severe form of premenstrual syndrome marked by intense melancholy, emotional lability with frequent tears, and a lack of interest in daily activities. To put it another way, emotional impairment is the most prominent trait.
This woman does not meet the diagnostic criteria for PMDD because she only has psychological symptoms of irritation and anxiety, as well as physical symptoms of headache and breast soreness (five symptoms).
PMDD diagnostic criteria include:
Symptoms and their timing
A) At least 5 symptoms must be present in the final week before menses, improve within a few days after menses, and become mild or non-existent in the week after menses in the majority of menstrual cycles.
Symptoms
B) At least one of the symptoms listed below must be present:
1) Affective lability that is noticeable (e.g., mood swings, feeling suddenly sad or tearful, or increased sensitivity to rejection)
2) Excessive irritation, wrath, or interpersonal conflicts
3) Depressed mood, hopelessness, and self-depreciating thoughts
4) Severe anxiety, tension, and/or a sense of being tense or on edge
C) In addition to the symptoms listed in criterion B, one (or more) of the following symptoms must also be present to reach a total of five symptoms.
1) Loss of enthusiasm for customary activities
2) Subjective concentration problems
3) Lethargy, fatigability, or a noticeable lack of energy
4) Significant changes in appetite, such as binge eating or specific food desires
5) Insomnia or hypersomnia
6) A feeling of being overwhelmed or powerless
7) Physical signs and symptoms include breast discomfort or swelling, joint or muscle pain, bloating, or weight gain.
Severity
D)The symptoms are linked to clinically substantial distress or interfere with employment, school, regular social activities, or interpersonal relationships.
E) Think about other mental illnesses. The disturbance isn’t only a sign of another disorder, like major depressive disorder, panic disorder, persistent depressive disorder (dysthymia), or a personality disorder (although it may co-occur with any of these disorders).
Confirmation of the condition
F)Prospective daily ratings throughout at least two symptomatic cycles should be used to confirm Criterion A. (although a provisional diagnosis may be made prior to this confirmation)
Other medical explanations are ruled out.
G) The symptoms aren’t caused by the physiological consequences of a substance (e.g., drug misuse, medication, or other treatment) or a medical condition (e.g., hyperthyroidism).
The severity of the symptoms cannot be explained by normal menstrual physiology.
Generalized anxiety disorder and depression are improbable diagnoses because these symptoms are temporally tied to menstrual cycles. -
This question is part of the following fields:
- Gynaecology
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Question 144
Correct
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Question 145
Incorrect
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Which of the following can be considered as a major contraindication for the use of medroxyprogesterone acetate (Provera)?
Your Answer: Past history of ovarian cysts
Correct Answer: History of breast cancer
Explanation:Contraindications of PROVERA (medroxyprogesterone acetate) include: undiagnosed abnormal genital bleeding, known, suspected, or history of breast cancer, known or suspected oestrogen- or progesterone-dependent neoplasia, active DVT, pulmonary embolism, or a history of these conditions, active arterial thromboembolic disease (for example, stroke and MI), or a history of these conditions, known anaphylactic reaction or angioedema, known liver impairment or disease, known or suspected pregnancy.
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This question is part of the following fields:
- Gynaecology
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Question 146
Correct
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Which of the following is the most common cause of abnormal vaginal discharge in patients of childbearing age?
Your Answer: Bacterial vaginosis
Explanation:Bacterial Vaginosis is a common condition which results in a foul smelling discharge from the vagina without any inflammation. It is the most common cause of abnormal PV discharge. Most of the women are asymptomatic carriers.
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This question is part of the following fields:
- Clinical Management
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Question 147
Correct
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During the inflammatory phase of wound healing what is the predominant cell type found in the wound during days 3-4?
Your Answer: Macrophages
Explanation:PMNs phagocytise debris and kill bacteria via free radicals (AKA respiratory burst). They also break down damaged tissue. PMNs typically undergo apoptosis after 48 hours. They are then engulfed and degraded by macrophages. Macrophages therefore become the predominant cell type in the wound on days 3-4.
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This question is part of the following fields:
- Physiology
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Question 148
Correct
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The most common aetiology for spontaneous abortion of a recognized first trimester gestation:
Your Answer: Chromosomal anomaly in 50-60% of gestations
Explanation:Chromosomal abnormalities are the most common cause of first trimester miscarriage and are detected in 50-85% of pregnancy tissue specimens after spontaneous miscarriage.
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This question is part of the following fields:
- Obstetrics
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Question 149
Correct
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Regarding electronic fetal monitoring, which one of the following statements is true?
Your Answer: Has low specificity but high sensitivity
Explanation:There are different ways of monitoring fetal heart rate during pregnancy. It can be done by just auscultation or by electronic fetal heart rate monitoring which is done with the help of an ultrasound machine and has a low specificity but high sensitivity.
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This question is part of the following fields:
- Physiology
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Question 150
Incorrect
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An 26 year old patient currently 9 weeks pregnant. This is her 1st pregnancy. She has been suffering with nausea and vomiting that has failed to respond to conservative measures including ginger, dietary changes and acupuncture. She wants to start medical therapy. Which of the following is 1st line drug treatment according to NICE guidance?
Your Answer: Domperidone
Correct Answer: Promethazine
Explanation:Promethazine or Cyclizine are 1st choice options for management of nausea and vomiting in pregnancy according to NICE. Prochlorperazine is also appropriate 1st line.
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This question is part of the following fields:
- Pharmacology
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Question 151
Correct
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The performance of a cervical cerclage at 14 weeks of gestation is determined by which of the following indications?
Your Answer: 2 or more consecutive prior second trimester pregnancy losses
Explanation:Cervical cerclage is performed as an attempt to prolong pregnancy in certain women who are at higher risk of preterm delivery.
There are three well-accepted indications for cervical cerclage placement. According to the American College of Obstetricians and Gynaecologists (ACOG), a history-indicated or prophylactic cerclage may be placed when there is a “history of one or more second-trimester pregnancy losses related to painless cervical dilation and in the absence of labour or abruptio placentae,” or if the woman had a prior cerclage placed due to cervical insufficiency in the second trimester.
An ultrasound-indicated cerclage may be considered for women who have a history of spontaneous loss or preterm birth at less than 34 weeks gestation if the cervical length in a current singleton pregnancy is noted to be less than 25 mm before 24 weeks of gestation. It is important to note that this recommendation is invalidated without the history of preterm birth.
Physical examination-indicated cerclage (also known as emergency or rescue cerclage) should be considered for patients with a singleton pregnancy at less than 24 weeks gestation with advanced cervical dilation in the absence of contractions, intraamniotic infection or placental abruption.
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This question is part of the following fields:
- Obstetrics
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Question 152
Incorrect
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A 27-year-old woman presented to the medical clinic for antenatal advice because she plans to get pregnant soon. However, she is worried about how she should change her diet once she becomes pregnant already.
Which of the following is considered the best to give to the patient in addition to giving folic acid?Your Answer: Vitamin D
Correct Answer: Iodine
Explanation:There is evidence that folic acid, iodine and vitamin D are important for reproductive outcomes. Folic acid and iodine supplementation is recommended for women planning to conceive and in pregnancy.
The recommended dose of folic acid for women without special considerations planning to conceive is 400-500 mcg. The recommended dose of folic acid for women with special considerations is 2-5 mg per day.
Women planning a pregnancy, including those with thyroid disease, should take iodine supplements in the dose of 150 mcg per day prior to and during pregnancy.
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This question is part of the following fields:
- Obstetrics
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Question 153
Incorrect
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A 27-year-old nulliparous woman presents with the complaint of malodorous vaginal discharge for the past one month. Patient has tried various over-the-counter vaginal douche products without any improvement. Her last menstrual period was 2 weeks ago, during which she noticed no change in her symptoms. In addition to the discharge, patient also experiences intermittent, crampy abdominal pain along with a feeling of gas passing through her vagina. Patient has had no history of surgeries in the past.
On examination her vital signs seems to be normal. Speculum examination shows a malodorous, tan vaginal discharge with an erythematous patch over the posterior vaginal wall. The cervix is nulliparous and has no visible lesions or areas of friability. A sinus with purulent drainage is found in the perianal skin.
Which among the following conditions will be the most likely underlying cause for this patient’s presentation?Your Answer: Blockage of the Bartholin gland duct
Correct Answer: Transmural inflammation of the bowel
Explanation:Common risk factors for Rectovaginal fistula are Pelvic radiation, Obstetric trauma, Pelvic surgery, Colon cancer, Diverticulitis and Crohn disease. Uncontrollable passage of gas &/or feces from the vagina is considered the common clinical feature of Rectovaginal fistula.
Diagnosis is done with the help of physical examination, fistulography, Magnetic resonance imaging and Endosonography.This patient, mentioned in the case, presents with malodorous vaginal discharge (ie, stool), gas passing through the vagina, and a posterior vaginal lesion most likely has a rectovaginal fistula, which is an aberrant connection between bowel and vagina. Although development of rectovaginal fistula is commonly associated with obstetric trauma or pelvic surgery, patients without these risk factors are recommended to be evaluated for other additional causes like gastrointestinal conditions.
This patient’s intermittent, crampy abdominal pain and perianal sinus in the setting of a rectovaginal fistula is most likely due to an underlying Crohn disease. Crohn disease, is a transmural inflammation of the gastrointestinal tract, which predisposes patients to bowel abscess, fissure, and fistula formation. Although the rectum is typically spared in Crohn disease, a non-healing, transmural ulcer present in the anal canal can progress to form a rectovaginal fistula.
In addition to standard Crohn disease management like anti-TNF inhibitors, glucocorticoids, etc patients with a rectovaginal fistula may require surgical correction.Bartholin gland cysts or abscesses can present with malodorous vaginal discharge; however, patients typically have a posterior vulvar mass located at the 4 or 8 o’clock position. In addition, Bartholin gland cysts will not present with crampy abdominal pain or passage of flatus or stool through the vagina.
Hidradenitis which is the chronic occlusion and inflammation of hair follicles, can cause groin abscesses with sinus tracts and associated purulent drainage. However, it is not associated with abdominal pain or malodorous vaginal discharge. In addition, this condition is typically multifocal and located in more than one intertriginous areas like axillary, inguinal or gluteal regions.
Cervical cancer or a retained foreign body in the vagina can cause malodorous vaginal discharge and abdominal pain. However, patients will typically have visible findings like cervical lesion, foreign body etc on speculum examination, and these neither are associated with the passage of flatus through the vagina.
Complications of Crohn disease include perianal disease like abscess, fissure and fistula like rectovaginal fistula, due to transmural inflammation of the gastrointestinal tract. Patients with a rectovaginal fistula typically presents with malodorous, tan vaginal discharge, passage of flatus through the vagina and a posterior vaginal lesion.
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This question is part of the following fields:
- Obstetrics
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Question 154
Correct
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A 30-year-old woman has a vaginal discharge with pH <4.5 and a very foul smell. What is the single most likely diagnosis?
Your Answer: Trichomoniasis
Explanation:Trichomoniasis is a common sexually transmitted infection caused by a parasite. In women, trichomoniasis can cause a foul-smelling vaginal discharge which might be white, grey, yellow or green, genital itching and painful urination.
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This question is part of the following fields:
- Gynaecology
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Question 155
Correct
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A 16 year old girl has been referred as she has amenorrhoea. She reports never having periods. Her mother and 2 sisters menarche was at age 12. On examination you note the patient is 152cm tall and BMI 29.0 and secondary sexual characteristics are not developed. Her FSH is elevated. Prolactin is normal. What is the suspected diagnosis?
Your Answer: Turner Syndrome
Explanation:Turner syndrome is the most common chromosomal abnormality in females occurring in 1 in 2500 live births. It is characterised by short stature, webbed neck and wide carrying angle. It is also associated with renal, endocrine and CVS abnormalities. In this condition the ovaries do not completely develop and do not produce oestrogen or oocytes, thus no secondary sexual characteristic develop and neither does the girl starts menstruating.
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This question is part of the following fields:
- Clinical Management
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Question 156
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 157
Correct
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Question 158
Incorrect
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A patient present to the clinic with a 1 day history of vaginal prolapse. Upon examination, the vagina is 1.5 cm below the vaginal plane. What grade is the prolapse according to the POP-Q classification?
Your Answer: Grade 4
Correct Answer: Grade 3
Explanation:Pelvic organ prolapse is a common condition amongst ageing women where a weakness in the pelvic support structures of the pelvic floor allows pelvic viscera to descend.
The Pelvic Organ Prolapse Quantification system (POP-Q) is useful for describing and staging the severity of the pelvic organ prolapse.
Grade 1: the most distal portion of the prolapse is more than 1 cm above the level of the hymen
Grade 2: the most distal portion of the prolapse is 1 cm or less proximal or distal to the hymenal plane
Grade 3: the most distal portion of the prolapse protrudes more than 1 cm below the hymen but protrudes no farther than 2 cm less than the total vaginal length (for example, not all of the vagina has prolapsed)
Grade 4: vaginal eversion complete -
This question is part of the following fields:
- Anatomy
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Question 159
Incorrect
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Normal physiological gut herniation occurs at how many weeks gestation?
Your Answer: 12 weeks
Correct Answer: 8 weeks
Explanation:At about 8-12 weeks gestation, normal physiological herniation of the fetal bowel occurs. The midgut protrudes into the base of the umbilicus, and undergoes a 90-degree anticlockwise rotation. When the abdominal cavity enlarges enough to fit the developing midgut, the intestines undergo another 180-degree rotation before returning to the abdominal cavity.
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This question is part of the following fields:
- Embryology
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Question 160
Correct
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Which of the following statements is true regarding heart rate in pregnancy?
Your Answer: Heart rate increases by 15 beats per minute
Explanation:During the first 12 weeks of pregnancy, cardiac output increases by about 30-50%. To maintain this increase, systemic vascular resistance decreases by 20-30%, while stroke volume and the heart rate increase by 25-30% and 15 beats per minute respectively.
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This question is part of the following fields:
- Physiology
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Question 161
Correct
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During normal pregnancy, the renal glomerular filtrate rate (GFR) can increase as much as:
Your Answer: 50%
Explanation:Pregnancy involves remarkable orchestration of physiologic changes. The kidneys are central players in the evolving hormonal milieu of pregnancy, responding and contributing to the changes in the environment for the pregnant woman and foetus. The functional impact of pregnancy on kidney physiology is widespread, involving practically all aspects of kidney function. The glomerular filtration rate increases 50% with subsequent decrease in serum creatinine, urea, and uric acid values.
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This question is part of the following fields:
- Physiology
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Question 162
Correct
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A 50-year-old female presents with a complaint of bloating and abdominal distension. History reveals she underwent hysterectomy 3 months ago. Which investigation should be carried out in this case?
Your Answer: Plain X-ray abdomen
Explanation:A complication of bilateral salpingo-oophorectomy and hysterectomy is the formation of adhesions in the GIT that can cause intestinal obstruction. Abdominal X-ray is sufficient to visualize any obstruction in the GIT.
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This question is part of the following fields:
- Gynaecology
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Question 163
Correct
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According to the NICE guidelines on intrapartum care a multiparous women with intact membranes should be offered amniotomy if there is inadequate progress of the active second stage of labour (in terms of rotation and/or descent of the presenting part) after how long?
Your Answer: 30 minutes
Explanation:Multiparous women active 2nd stage labour: Suspect delay if progress inadequate after 30 minutes Diagnose delay if progress inadequate after 1 hour If delay is suspected amniotomy should be offered if membranes are intact If delay diagnosed then preparations should be made for C-section Nulliparous women active 2nd stage labour: Suspect delay if progress inadequate after 1 hour Diagnose delay if progress inadequate after 2 hours If delay is suspected amniotomy should be offered if membranes are intact If delay diagnosed then preparations should be made for C-section
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This question is part of the following fields:
- Clinical Management
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Question 164
Incorrect
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You are asked to assess a patients perineal tear following labour by vaginal delivery. You note a laceration that extends approximately a quarter of the thickness through the external anal sphincter. How would you classify this tear?
Your Answer: 2nd
Correct Answer: 3a
Explanation:1. First-degree trauma corresponds to lacerations of the skin/vaginal epithelium alone.
2. Second-degree tears involve perineal muscles and therefore include episiotomies.
3. Third-degree extensions involve any part of the anal sphincter complex (external and internal sphincters):
i Less than 50 per cent of the external anal
sphincter is torn.
ii More than 50 per cent of the external anal
sphincter is torn.
iii Tear involves the internal anal sphincter
(usually there is complete disruption of the
external sphincter).
4. Fourth-degree tears involve injury to the anal sphincter complex extending into the rectal mucosa. -
This question is part of the following fields:
- Anatomy
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Question 165
Incorrect
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What frequency is used for trans-abdominal ultrasound?
Your Answer: 7.5 MHz
Correct Answer: 3.0 MHz
Explanation:The transabdominal ultrasound uses a frequency of 3.5-7 MHz emitted from a transducer. Transvaginal 5-7.5 MHz (post bladder void.
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This question is part of the following fields:
- Data Interpretation
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Question 166
Correct
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Maternal mortality rate is lowest in which age group?
Your Answer: 20 - 30
Explanation:The maternal mortality rate starts low and raises steeply after the age of 30 years. The lowest mortality rate recorded among women is between 19-30 years of age group.
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This question is part of the following fields:
- Physiology
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Question 167
Incorrect
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Beta and Delta Thalassemia are associated with abnormalities to which chromosome
Your Answer: Chromosome 6
Correct Answer: Chromosome 11
Explanation:Fetal haemoglobin (HBF) is the main haemoglobin type in the foetus and persists after birth for around 6 months. Fetal haemoglobin is composed of two alpha and two gamma subunits The alpha globulin chain is coded for by genes on Chromosome 16. Alpha Thalassemia are therefore associated with Chromosome16 defects The beta and delta globulin chains are coded for by genes on Chromosome 11. Beta and Delta Thalassemia are therefore associated with Chromosome 11 Defects
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This question is part of the following fields:
- Endocrinology
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Question 168
Correct
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A 29-year-old woman presents to the emergency department of your hospital complaining of fever, she had given birth to a healthy male baby four days ago. During vaginal delivery, she sustained small vaginal laceration, suture repair was not done as the lesion were small. Presently she is breastfeeding her baby.
Physical examination shows no uterine tenderness and the rest of the examinations were unremarkable.
Which of the following can be the most likely cause of this Patient's fever?Your Answer: Infection of the unrepaired vaginal laceration
Explanation:As the time of onset of fever is the 4th day of postpartum and absence of uterine tenderness on exam makes infection of vaginal laceration the most likely cause of this presentation.
Exquisite uterine tenderness will be experienced in case of endometritis and symptoms are expected to start much earlier like by 2-3 days of postpartum.
UTI is often expected on days one or two of postpartum, also there are no urinary symptoms suggestive of UTI
Breast engorgement usually develops by 7th -2st day of postpartum and in the given case it’s too soon for it to occur.
As it is expected during the first 2 hours postpartum, Atelectasis is unlikely to be the cause of symptoms in the given case.
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This question is part of the following fields:
- Obstetrics
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Question 169
Incorrect
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Question 170
Correct
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You review a 58 year old patient in clinic. She asks what the results of her recent DEXA scan are. You note her hip BMD hip T-score is -1.4. You note she has a history of olecranon fracture 4 years ago. What is her classification according to WHO criteria?
Your Answer: Osteopenia
Explanation:Her T-score puts her in the osteopenic range. The presence of fragility fractures is more important in the osteoporotic patient. Olecranon fracture is not a typical fragility fracture.
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This question is part of the following fields:
- Endocrinology
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Question 171
Incorrect
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Among the following, which is the most common method used for termination of a pregnancy before 20 weeks in Australia?
Your Answer: Mifepristone
Correct Answer: Suction and curettage
Explanation:Medical abortion is preferred from 4 to 9 weeks of gestation and in Australia, suction curettage is the most frequently used method of abortion as it is considered useful from 6 to 14 weeks of gestation.
Mifepristone is a synthetic anti-progesterone, which is found to be effective for abortion when combined with misoprostol. There are evidences which suggest the effectiveness of misoprostol and mifepristone in both first and second trimesters. It is most commonly administered as a single dose of mifepristone followed by misoprostol, a prostaglandin, given orally or vaginally two days later. Prostaglandin can be repeated at an interval of 4 hours if required.
As the vaginal use shows only few gastrointestinal side effects Misoprostol is more effective and better tolerated vaginally than orally. Misoprostol is not approved for its use in termination of pregnancy, but is available in the market due to its indications in other conditions.
Methotrexate can be used orally or as an intramuscular injection followed by misoprostol up to seven days later, but this also is not a preferred method for termination of pregnancy in Australia. -
This question is part of the following fields:
- Obstetrics
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Question 172
Correct
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Management of a patient with threatened abortion includes all of the following, EXCEPT:
Your Answer: Dilatation and curettage
Explanation:Patients with a threatened abortion should be managed expectantly until their symptoms resolve. Patients should be monitored for progression to an inevitable, incomplete, or complete abortion. Analgesia will help relieve pain from cramping. Bed rest has not been shown to improve outcomes but commonly is recommended. Physical activity precautions and abstinence from sexual intercourse are also commonly advised. Repeat pelvic ultrasound weekly until a viable pregnancy is confirmed or excluded. A miscarriage cannot be avoided or prevented, and the patients should be educated as such. Intercourse and tampons should be avoided to decrease the chance of infection. A warning should be given to the patient to return to the emergency department if there is heavy bleeding or if the patient is experiencing light-headedness or dizziness. Heavy bleeding is defined as more than one pad per hour for six hours. The patient should also be given instructions to return if they experience increased pain or fever. All patients with vaginal bleeding who are Rh-negative should be treated with Rhogam. Because the total fetal blood volume in less than 4.2 mL at 12 weeks, the likelihood of fetal blood mixture is small in the first trimester. A smaller RhoGAM dose can be considered in the first trimester. A dose of 50 micrograms to 150 micrograms has been recommended. A full dose can also be used. Rhogam should ideally be administered before discharge. However, it can also be administered by the patient’s obstetrician within 72 hours if the vaginal bleeding has been present for several days or weeks.
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This question is part of the following fields:
- Obstetrics
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Question 173
Correct
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Which of the following statements regarding the Vaginal artery is typically TRUE?
Your Answer: It arises from the Internal iliac artery
Explanation:The Vaginal artery, like the Uterine artery is typically a branch of the Internal Iliac artery. It can sometimes arise as a branch of the Uterine artery so it is important to read the question (if the stem stated it CAN arise from the Uterine artery then that would be true)
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This question is part of the following fields:
- Anatomy
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Question 174
Correct
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Which of the following best describes the muscles assessed by urodynamic testing?
Your Answer: Detrusor and urethral sphincter muscles
Explanation:Urodynamics is a broad term that comprises cytometry, urethral pressure measurement, leak point pressure, pressure flow studies, EMG and videourodynamics. They assess the function of the bladder and urethra as a functional unit. This may provide information such as the site of bladder outlet obstruction, overactivity of the detrusor and sphincter weakness. In muscular terms the detrusor and sphincter muscles are being assessed.
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This question is part of the following fields:
- Biophysics
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Question 175
Incorrect
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A 77 year old woman undergoes staging investigations for endometrial carcinoma. This shows invasion of the inguinal lymph nodes. What is this patients 5-year survival?
Your Answer: 45-60%
Correct Answer: 15%
Explanation:Lymph node involvement means that the carcinoma is stage 4. The 5 year survival of stage 4 endometrial carcinoma is 16%.
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This question is part of the following fields:
- Clinical Management
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Question 176
Correct
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In normal pregnancy, levels of all of the following hormones increases, EXCEPT:
Your Answer: Parathyroid hormone (PTH) in the 2nd & 3rd trimesters
Explanation:In order to maintain fetal bone growth, the maternal compartment undergoes adjustments that provide a net transfer of sufficient calcium to the foetus. Maternal compartment changes that permit calcium accumulation include increases in maternal dietary intake, increases in maternal 1, 25-dihydroxyvitamin D3 levels, and increases in parathyroid hormone (PTH) levels. The levels of total calcium and phosphorus decline in maternal serum, but ionized calcium levels remain unchanged. During pregnancy, the placenta forms a calcium pump in which a gradient of calcium and phosphorus is established which favours the foetus. Thus, circulating fetal calcium and phosphorus levels increase steadily throughout gestation. Furthermore, fetal levels of total and ionized calcium, as well as phosphorus, exceed maternal levels at term. By 10-12 weeks’ gestation, the fetal parathyroid glands secrete PTH. Fetal plasma levels of PTH are low during gestation, but increase after delivery.
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This question is part of the following fields:
- Endocrinology
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Question 177
Correct
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A low APGAR score at one minute:
Your Answer: Indicates the need for immediate resuscitation
Explanation:The treatment of asphyxia starts with the correct perinatal management of high-risk pregnancies. The management of the hypoxic-ischemic new-borns in the delivery room is the second fundamental step of the treatment. Low Apgar scores and need for cardiopulmonary resuscitation at birth are common but nonspecific findings. Most new-borns respond rapidly to resuscitation and make a full recovery. The outcomes for new-borns who do not respond to resuscitation by 10 minutes of age are very poor, with a very low probability of surviving without severe disability. Resuscitation in room air is advised for term new-borns, since the use of 100% oxygen is associated with worse outcomes compared to the use of room air.
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This question is part of the following fields:
- Obstetrics
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Question 178
Correct
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Which hormone is responsible for contraction of myoepithelial cells in lactation?
Your Answer: Oxytocin
Explanation:Oxytocin is responsible for the let down mechanism that occurs during breast feeding in which the myothelial cells contract and push the milk into the ductules.
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This question is part of the following fields:
- Clinical Management
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Question 179
Correct
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Bishop scoring is used for:
Your Answer: The success rate of induction of the labour
Explanation:The Bishop score is a system used by medical professionals to decide how likely it is that you will go into labour soon. They use it to determine whether they should recommend induction, and how likely it is that an induction will result in a vaginal birth.
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This question is part of the following fields:
- Obstetrics
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Question 180
Correct
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The COCP (Combined Oral Contraceptive Pill) causes all of the following biochemical effects EXCEPT?
Your Answer: Elevate FSH
Explanation:COCP’s act both centrally and peripherally. They inhibit ovulation. Both oestrogen and progestogen supress the release of FSH and LH hence preventing ovulation. Peripherally it acts by making the endometrium atrophic and hostile towards implantation. It also alters the cervical mucus and prevents the sperm from ascending the uterine cavity.
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This question is part of the following fields:
- Clinical Management
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Question 181
Correct
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Stages of labour
Your Answer: The third stage ends with the delivery of the placenta and membranes
Explanation:First stage: The latent phase is generally defined as beginning at the point at which the woman perceives regular uterine contractions. A definition of active labour in a British journal was having contractions more frequent than every 5 minutes, in addition to either a cervical dilation of 3 cm or more or a cervical effacement of 80% or more.
Second stage: fetal expulsion begins when the cervix is fully dilated, and ends when the baby is born.
Third stage: placenta delivery – The period from just after the foetus is expelled until just after the placenta is expelled is called the third stage of labour or the involution stage.
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This question is part of the following fields:
- Clinical Management
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Question 182
Correct
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Urinary incontinence has brought a 69-year-old woman to your clinic. When she laughs, sneezes, or coughs, as well as during activity, she experiences minor quantities of urine incontinence.
Which of the following is the most appropriate management next step?Your Answer: Pelvic floor muscles exercise
Explanation:Pelvic floor muscle exercises are the mainstay of behavioural therapy for stress incontinence. Up to 38 percent of patients with stress incontinence alone who follow a pelvic floor muscle exercise regimen for at least three months experience a cure.
Weighted cones or topical steroids can be used as adjuvants but are not sufficient when used alone.
Tension free vaginal tape and Burch’s colposuspension are considered for patients who fail to respond to conservative management strategies.
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This question is part of the following fields:
- Gynaecology
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Question 183
Incorrect
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A 29 year old obese woman presents complaining of difficult or painful sexual intercourse and dysmenorrhea. She is requesting a reversible contraceptive method. Which of the following would be most suitable?
Your Answer: Combined Oral Contraceptive Pill (COCP)
Correct Answer: Mirena
Explanation:Mirena is a form of contraception also indicated for the treatment of heavy menstrual bleeding and the management of dysmenorrhea, being able to reduce the latter considerably.
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This question is part of the following fields:
- Gynaecology
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Question 184
Incorrect
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A patient attends the maternity unit as her waters have broken but she hasn't had contractions. She is 39+6 weeks gestation. Speculum examination confirms prelabour rupture of membranes (PROM). According to NICE guidelines after what time period should induction be offered?
Your Answer: 12 hours
Correct Answer: 24 hours
Explanation:Induction of labour is appropriate approximately 24 hours after rupture of the membranes.
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This question is part of the following fields:
- Clinical Management
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Question 185
Correct
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The ascending colon drains into the superior mesenteric vein (SMV). What vein does the SMV drain into?
Your 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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Question 186
Correct
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A 30-year-old primigravida woman presented to the clinic for her first antenatal check-up. Upon interview, it was noted that she was taking folic acid along with some other nutritional supplements as medication.
All of the following are considered correct regarding neural tube defects and folate before and during pregnancy, except:Your Answer: Prevalence of neural tube defects among non-indigenous population is almost double than that in Aboriginal and Torres Strait Islander babies
Explanation:Neural tube defects (NTDs) are common complex congenital malformations resulting from failure of the neural tube closure during embryogenesis. It is established that folic acid supplementation decreases the prevalence of NTDs, which has led to national public health policies regarding folic acid.
Neural tube defects (NTD) were 43% more common in Indigenous than in non-Indigenous infants in Western Australia in the 1980s, and there has been a fall in NTD overall in Western Australia since promotion of folate and voluntary fortification of food has occurred.
Women should take 5 mg/d of folic acid for the 2 months before conception and during the first trimester.
Women planning pregnancy might be exposed to medications with known antifolate activities affecting different parts of the folic acid metabolic cascade. A relatively large number of epidemiologic studies have shown an increased risk of NTDs among babies exposed in early gestation to antiepileptic drugs (carbamazepine, valproate, barbiturates), sulphonamides, or methotrexate. Hence, whenever women use these medications, or have used them near conception, they should take 5 mg/d of folic acid until the end of the first trimester of pregnancy.
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This question is part of the following fields:
- Obstetrics
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Question 187
Correct
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Question 188
Correct
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Following parturition uterine contractions called Afterpains may typically continue for how long?
Your Answer: None of the above
Explanation:Afterpains may continue for 2-3 days (so none of the above). Breastfeeding may intensify pain due to stimulation of Oxytocin which causes uterine contractions
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This question is part of the following fields:
- Clinical Management
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Question 189
Correct
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Regarding cardiac examination during pregnancy which of the following findings should be considered pathological
Your Answer: Diastolic murmur
Explanation:Diastolic murmurs should be considered pathological until proven otherwise. The following are common and typically benign findings in pregnancy: A third heart sound after mid-pregnancy. Systolic flow murmurs are common. Left axis deviation on ECG is common, Sagging ST segments and inversion or flattening of the T wave in lead III may also occur
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This question is part of the following fields:
- Physiology
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Question 190
Correct
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A 32-year-old gravida 3 para 2 presents for routine prenatal care. The patient is at 14 weeks estimated gestational age by last menstrual period, and ultrasonography at 8 weeks gestation was consistent with these dates. Fetal heart tones are not heard by handheld Doppler. Transvaginal ultrasonography reveals an intrauterine foetus without evidence of fetal cardiac activity. The patient has not had any bleeding or cramping, and otherwise feels fine. A pelvic examination reveals a closed cervix without any signs of bleeding or products of conception.
Which one of the following is the most likely cause of this presentation?Your Answer: A missed abortion
Explanation:In this case, the patient has a missed abortion, which is defined as a dead foetus or embryo without passage of tissue and with a closed cervix. This condition often presents with failure to detect fetal heart tones or a lack of growth in uterine size.
– By 14 weeks estimated gestational age, fetal heart tones should be detected by both handheld Doppler and ultrasonography.
– An inevitable abortion presents with a dilated cervix, but no passage of fetal tissue.
– A blighted ovum involves failure of the embryo to develop, despite the presence of a gestational sac and placental tissue. -
This question is part of the following fields:
- Obstetrics
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Question 191
Correct
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Regarding the urinary bladder, what type of epithelium lines it?
Your Answer: Transitional
Explanation:The urinary bladder, and most of the urinary structures are lined by epithelium called the urothelium, or the transitional epithelium. This stratified lining is divided into three parts, an apical layer, an intermediate layer and a basal layer. The transitional epithelium is available to stretch to accommodate the increased volume when the bladder is distended, without structural damage.
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This question is part of the following fields:
- Anatomy
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Question 192
Correct
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A 48-year-old woman presents to the clinic complaining of a one week history of light vaginal bleeding.
Her past medical history reveals she had a lumpectomy, postoperative radiotherapy, adjuvant chemotherapy and tamoxifen therapy 3 years ago as treatment for an oestrogen receptor-positive breast malignancy.
She was prescribed tamoxifen in a dose of 10mg per day to take for the next five years.
Since she completed her chemotherapy three years ago, she has no menstrual periods.
What is the most probable cause of her current bleeding?Your Answer: Endometrial polyp formation due to the tamoxifen.
Explanation:The most likely cause of her bleeding is an endometrial polyp formation due to the tamoxifen.
Tamoxifen is often prescribed to decrease risk of breast cancer recurrence in premenopausal women with oestrogen receptor-positive cancers.
As with any medication, it has known side effects, which include endometrial polyp formation, subendometrial oedema and, rarely, endometrial carcinoma.
A polyp or carcinoma can cause uterine bleeding, but a polyp is more likely to occur.
Routine endometrial thickness screening is not recommended in all women taking tamoxifen. However, in cases of abnormal bleeding, ultrasound assessment of endometrial thickness, hysteroscopy and curettage are indicated to assess the endometrium in more detail.
Tamoxifen is not associated with endometrial atrophy.
Endometrial metastasis from a breast cancer is rare, and tamoxifen would not usually induce follicular development in a woman who has had chemotherapy and resultant amenorrhoea.
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This question is part of the following fields:
- Gynaecology
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Question 193
Correct
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Due to her inability to conceive, a 28-year-old nulligravid lady comes to the office with her husband. The patient and her spouse had been having intercourse every other day since they stopped using barrier contraception a year ago. Every 28 days, the patient experiences a 5-day period with two days of high flow. She has transient pelvic pain 14 days after her menstruation begins, but intercourse is painless.
The patient was admitted to the hospital in her late teens for a pelvic infection, and she had discomfort with intercourse, discharge, and fever during her stay. She hasn't had any previous medical or surgical procedures. Her younger sibling suffers from polycystic ovarian syndrome. The patient's husband is 32 years old, has no children, and a normal semen analysis. The patient has a blood pressure of 130/80 mm Hg and a pulse rate of 86 beats per minute. There are no anomalies on physical examination.
Which of the following is the most appropriate next step in this patient's care?Your Answer: Hysterosalpingogram
Explanation:Primary infertility is defined as the inability to conceive after a year of unprotected, timed sexual intercourse in a nulliparous patient under the age of 35. (After 35 years of age, infertility testing can begin after 6 months.) Because the patient’s partner’s sperm analysis is normal, female factor infertility is the most likely explanation. This patient’s adolescent hospitalizations are likely due to pelvic inflammatory disease (PID), a common cause of infertility caused by tubal scarring and blockage.
A hysterosalpingogram, which includes infusing radiocontrast into the cervix under fluoroscopy, is the first-line imaging technique for determining fallopian tube patency. A hysterosalpingogram is a non-invasive procedure that can detect uterine cavity irregularities (e.g., bicornuate uterus).
Peritoneal adhesions and endometriosis can be seen and treated directly using laparoscopy.
PID-related scarring inside the fallopian tubes can be assessed by laparoscopy with chromotubation; however, it is invasive, expensive, and not utilized first-line.
Ovulation is detected using a mid-cycle LH level. The LH surge can be detected in urine and serum 36 hours before ovulation. Regular menstrual periods are characterized by mittelschmerz (mid-cycle pelvic pain), which indicates ovulation. As a result, an LH level would be useless.
Ovarian reserve begins to deteriorate around the age of 35, and serum FSH levels rise in women who are losing their ability to ovulate. Because this patient is much younger and has regular periods, a drop in ovum quantity is unlikely to be the reason for infertility.
Increased serum androgen levels can prevent ovulation by inhibiting the release of GnRH and FSH through feedback inhibition. The patient has regular cycles and no hyperandrogenic symptoms, despite her sister having polycystic ovarian syndrome (e.g., hirsutism, irregular menses).
In a nulliparous patient under the age of 35, primary infertility is defined as the inability to conceive after a year of unprotected sexual intercourse. A hysterosalpingogram is used to determine the cause of infertility, such as tubal blockage caused by a previous pelvic infection.
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This question is part of the following fields:
- Gynaecology
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Question 194
Correct
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An 19-year old female came in at the clinic for her first prenatal visit. She claims to have had regular menstrual cycles even while she was on oral contraceptives (OCP). 20 weeks ago, she stopped taking her OCPs and had a menstrual period few days after. No vaginal bleeding or fluid loss were noted since then. On physical examination, the uterus is palpated right above pubic symphysis. Fetal heartbeats are evident on handheld Doppler ultrasound. Which of the statements can mostly explain the difference between the dates and uterine size?
Your Answer: Ovulation did not occur until 6-8 weeks after her last period.
Explanation:When the palpated uterine size is in discrepancy with the expected size based on the duration of amenorrhoea, it can have several causes including reduced fluid volume or fetal growth (both of which are more common when there is fetal malformation), or miscalculated age of gestation as a result of wrong dates or actual ovulation occurring at a later date than expected. Reduced fluid volume and fetal growth are the most likely aetiologies during the third trimester of pregnancy, unlike in this patient at 20 weeks age of gestation.
Premature rupture of membranes is less likely the cause when there is negative vaginal fluid loss like this patient.
The most likely cause in this case is that ovulation did not occur as expected, especially when the patient ceased her OCPs during this period. In some instances, ovulation can occur 2 weeks later in about 50% of women, 6 weeks later in 90%, and may still not occur 12 months later in 1% of women.
The other listed statements are unlikely to explain the discrepancies in dates and the observed uterine size in this patient.
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This question is part of the following fields:
- Obstetrics
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Question 195
Incorrect
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What is the definition of puberty in girls?
Your Answer: Development of secondary sexual characteristics
Correct Answer: Becoming capable of sexual reproduction
Explanation:Puberty is the process of reproductive and sexual development and the maturation which changes a child into an adult.
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This question is part of the following fields:
- Endocrinology
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Question 196
Incorrect
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In the 3rd trimester anaemia is defined by?
Your Answer: Haemoglobin < 105 g/l
Correct Answer:
Explanation:Haemoglobin decreases from 13.3 g/dL to 10.5 g/dL from the start of pregnancy i.e. First trimester till the 3rd trimester.
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This question is part of the following fields:
- Clinical Management
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Question 197
Incorrect
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Under which one of the following conditions is the pelvic inlet felt to be contracted?
Your Answer: The transverse diameter is only 10 cm
Correct Answer:
Explanation:Contracted pelvis occurs when one or more of its diameters is reduced so that it interferes with the normal mechanism of labour. A transverse diameter below 11 cm will result in difficult delivery of the foetus and C-section will be the better option in that case
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This question is part of the following fields:
- Anatomy
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Question 198
Correct
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Question 199
Correct
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Which major hormone of pregnancy is produced by the placenta from 16-hydroxydehydroepiandrosterone sulphate (16-OH DHEAS)?
Your Answer: Estriol
Explanation:The placenta produces Estriol from 16-OH DHEAS. Estriol is the major oestrogen (oestrogen) of pregnancy and the placenta is the primary site of production. Pregnenolone is synthesised by the placenta from cholesterol and this is converted to dehydroepiandrosterone (DHEA) in the fetal adrenal gland
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This question is part of the following fields:
- Endocrinology
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Question 200
Incorrect
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In developed countries, Group B streptococcus is the leading cause of early-onset neonatal sepsis. The risk of early onset neonatal Group B Streptococcus sepsis can be reduced by screening for Group B streptococcus status and by the use of intrapartum antibiotics.
From the below given statements, which is false regarding Group B streptococcus screening and intrapartum antibiotics prophylaxis?Your Answer: Intrapartum antibiotic prophylaxis should be offered to all women at increased risk of early onset Group B streptococcus sepsis
Correct Answer: For elective caesarian section before the commencement of labour give antibiotics prophylaxis is recommended, irrespective of Group B streptococci carriage
Explanation:A rectovaginal swab taken for Group B streptococci culture should be done in women presenting with threatened preterm labour
If labour is establishes, intrapartum antibiotic prophylaxis for Group B streptococci should be commenced and continued until delivery. In cases were labour is not establish, prophylaxis for Group B streptococci should be ceased and should be re-established only if the culture is found to be positive, that too at the time of onset of labour.
Strategies acceptable for reducing early onset Group B streptococci sepsis includes universal culture-based screening using combined low vaginal plus or minus anorectal swab at 35-37 weeks gestation or a clinical risk factor based approach.
No additional prophylaxis is recommended irrespective of Group B streptococci carriage, for elective cesarean section before the commencement of labour. However, if a woman who commences labour or has spontaneous rupture of the membranes before her planned Caesarean section is screened positive for Group B streptococci, she should receive intrapartum antibiotic prophylaxis while awaiting delivery.
Although there is little direct evidence to guide this practice, consideration of the above mentioned evidences it is recommendation that, every women with unknown Group B streptococci status at the time of delivery should be managed according to the presence of intrapartum risk factors.
All women at increased risk of early onset Group B streptococci sepsis must be offered an intrapartum antibiotic prophylaxis with IV penicillin-G or ampicillin. -
This question is part of the following fields:
- Obstetrics
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