Part 2 MRCOG 500 EMQs and SBAs 9781108627801

Table of contents :
Cover......Page 1
01.0_pp_i_ii_Part_2_MRCOG_500_EMQs_and_SBAs......Page 2
04.0_pp_v_vi_Contents......Page 5
05.0_pp_vii_viii_Foreword......Page 6
06.0_pp_ix_x_Preface......Page 7
07.0_pp_xi_xii_Author_profiles......Page 8
08.0_pp_xiii_xiv_Acknowledgements......Page 9
09.0_pp_xv_xvi_Normal_ranges_non-pregnant_used_in_the_MRCOG......Page 10
10.0_pp_xvii_xviii_Abbreviations......Page 11
11.0_pp_xix_xx_Introduction......Page 13
12.0_pp_1_6_Clinical_skills......Page 14
13.0_pp_7_13_Teaching_and_assessment......Page 20
14.0_pp_14_20_IT_clinical_governance_and_research......Page 27
15.0_pp_21_29_Core_surgical_skills......Page 34
16.0_pp_30_40_Postoperative_care......Page 43
17.0_pp_41_51_Surgical_procedures......Page 54
18.0_pp_52_90_Antenatal_care......Page 65
19.0_pp_91_121_Maternal_medicine......Page 104
20.0_pp_122_132_Management_of_labour......Page 135
21.0_pp_133_143_Management_of_delivery......Page 146
22.0_pp_144_154_Postpartum_problems......Page 157
23.0_pp_155_182_Gynaecological_problems......Page 168
24.0_pp_183_198_Subfertility......Page 196
25.0_pp_199_208_Sexual_and_reproductive_health......Page 212
26.0_pp_209_224_Early_pregnancy_care......Page 222
27.0_pp_225_243_Gynaecological_oncology......Page 238
28.0_pp_244_264_Urogynaecology_and_pelvic_floor_problems......Page 257
29.0_pp_265_274_Index......Page 278

Citation preview

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Part 2 MRCOG: 500 EMQs and SBAs

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Bidyut Kumar

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Shrewsbury and Telford Hospital NHS Trust and Keele University School of Medicine

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Shrewsbury and Telford Hospital NHS Trust

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Guy Calcott

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Wrexham Maelor Hospital, Betsi Cadwaladr University Health Board

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Andrew Sizer

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Part 2 MRCOG: 500 EMQs and SBAs

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One Liberty Plaza, 20th Floor, New York, NY 10006, USA

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University Printing House, Cambridge CB2 8BS, United Kingdom

477 Williamstown Road, Port Melbourne, VIC 3207, Australia

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79 Anson Road, #06-04/06, Singapore 079906

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314–321, 3rd Floor, Plot 3, Splendor Forum, Jasola District Centre, New Delhi – 110025, India

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Cambridge University Press is part of the University of Cambridge.

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It furthers the University’s mission by disseminating knowledge in the pursuit of education, learning, and research at the highest international levels of excellence.

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www.cambridge.org Information on this title: www.cambridge.org/9781108709712 DOI: 10.1017/9781108627801

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This publication is in copyright. Subject to statutory exception and to the provisions of relevant collective licensing agreements, no reproduction of any part may take place without the written permission of Cambridge University Press.

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Printed and bound in Great Britain by Clays Ltd, Elcograf S.p.A.

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ISBN 978–1-108–70971-2 Paperback

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Every effort has been made in preparing this book to provide accurate and up-to-date information that is in accord with accepted standards and practice at the time of publication. Although case histories are drawn from actual cases, every effort has been made to disguise the identities of the individuals involved. Nevertheless, the authors, editors and publishers can make no warranties that the information contained herein is totally free from error, not least because clinical standards are constantly changing through research and regulation. The authors, editors and publishers therefore disclaim all liability for direct or consequential damages resulting from the use of material contained in this book. Readers are strongly advised to pay careful attention to information provided by the manufacturer of any drugs or equipment that they plan to use.

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Cambridge University Press has no responsibility for the persistence or accuracy of URLs for external or third-party internet websites referred to in this publication and does not guarantee that any content on such websites is, or will remain, accurate or appropriate.

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A catalogue record for this publication is available from the British Library.

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First published 2019

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© Andrew Sizer, Bidyut Kumar and Guy Calcott 2019

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Module 14 Subfertility 183

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Module 15 Sexual and reproductive health 199

Module 5 Core surgical skills 21

Module 16 Early pregnancy care 209

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Index  265

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Module 11 Management of delivery 133

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Module 12 Postpartum problems 144

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Module 10 Management of labour 122

Module 18 Urogynaecology and pelvic floor problems 244

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Module 9 Maternal medicine 91

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Module 8 Antenatal care 52

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Module 17 Gynaecological oncology 225

Module 7 Surgical procedures 41

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Module 3 IT, clinical governance and research 14

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Module 2 Teaching and assessment 7

Module 13 Gynaecological problems 155

Module 6 Postoperative care 30

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Foreword  vii Preface  ix Author profiles  xi Acknowledgements  xiii Normal ranges (non-pregnant) used in the MRCOG   xv Abbreviations  xvii Introduction  xix

Module 1 Clinical skills 1

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Contents

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Dr Lisa Joels MB ChB MD FRCOG FHEA Chair of the RCOG Examination and Assessment Committee 2015–18

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Membership of the Royal College of Obstetricians and Gynaecologists (MRCOG) is a highly regarded qualification throughout the world and confirms that the successful candidate has achieved a widely respected standard of knowledge, skills, attitudes and competencies in the practice of obstetrics and gynaecology. The award of MRCOG is made after successfully passing all three parts of the MRCOG examination. The Part 2 MRCOG is designed to test the skills necessary to pass from core clinical training (ST1– ST5) to higher specialist training (ST6 and ST7), and represents a significant hurdle in this transition. This book of practice questions is an invaluable resource for candidates preparing for the Part 2 MRCOG examination. Written by experienced examiners and members of RCOG examination subcommittees, this book gives candidates the most relevant and authentic practice in preparation for the examination of all the currently available resources. The authors have vast expertise in writing examination questions and coaching candidates through courses, and therefore this book represents the most relevant examination preparation material available to date. The authors make very clear that this book should be used in addition to the standard revision resources as recommended by the RCOG but have helpfully referenced each and every explanation of the correct answer to enable the candidate to focus their revision of each particular topic. This resource should become an essential part of examination preparation for all candidates attempting the Part 2 MRCOG examination.

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Foreword

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The current format of the Part 2 MRCOG examination is now well established with the change to written papers containing single best answer (SBAs) and extended matching questions (EMQs) commencing in March 2015. The Part 2 MRCOG examination is primarily concerned with testing candidates’ knowledge of the entire specialty of obstetrics and gynaecology as defined by the Royal College of Obstetricians and Gynaecologists (RCOG) curriculum. The new Part 3 examination now provides the clinical assessment. It is always preferable to enter an examination having had ample opportunity to practise the type of questions with which one will be faced. To this end, we have produced this book containing 250 SBA and 250 EMQ questions. We have mapped the questions across all the modules of the curriculum that appear in the Part 2 MRCOG examination and have used the following sources as our primary references: • RCOG guidelines • National Institute for Health and Care Excellence (NICE) guidelines • Articles in The Obstetrician & Gynaecologist. The styles of the 500 questions are different, but this will mimic the actual examination, since numerous authors have contributed to the Part 2 MRCOG question bank. In this book, we have tried to conform to the style of questions found in the Part 2 MRCOG examination but have deliberately separated the questions into the different modules of the syllabus. In this way, candidates will be able to test their knowledge in each of the modules after they have completed the necessary reading for that particular module. For each answer, we have provided a brief explanation and a reference to allow further or more in-depth reading of that subject. The explanations given here are not meant to replace the wider reading of the subject that is required to attain the level necessary to pass the Part 2 MRCOG examination. Knowledge accumulates, practice alters and guidelines change. We will be grateful for feedback. We hope that candidates for the Part 2 MRCOG will find this book helpful in their preparation for the Part 2 MRCOG examination.

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Preface

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Guy Calcott Guy Calcott is a newly appointed Consultant Obstetrician and Gynaecologist at the Shrewsbury and Telford Hospital NHS Trust with a special interest in high-risk obstetrics, maternal medicine and early pregnancy care. He qualified with a distinction in Medicine and Surgery from Imperial College School of Medicine in 2009 and a First Class Honours Bachelor of Science in Surgery and Anaesthesia. He completed foundation training and early obstetrics and gynaecology training at North West Thames before relocating to the West Midlands in 2013. He completed the MRCOG in 2015 and has been presenting and teaching on Part 2 MRCOG courses two to three times per year since 2016.

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Bidyut Kumar Bid Kumar was appointed as a Consultant Obstetrician and Gynaecologist in 2001. He has been a RCOG tutor and a member of the Wales Deanery Specialty Training Committee. He is an honorary lecturer at Cardiff University Medical School and an honorary Senior Lecturer at Bangor University. He is a current Part 3 MRCOG examiner and has a number of current and former roles at the RCOG including the Part 2 course faculty, Part 2 MRCOG EMQ subcommittee and Green-top Guideline committee. He is Editor-in-Chief of Ultrasound, the journal of the British Medical Ultrasound Society, and an Associate Editor of the The Obstetrician & Gynaecologist. He actively contributes to the education and continued professional development of many healthcare professionals. Bid is an editor-author of Fetal Medicine, a textbook of the RCOG’s Advanced Skills series (2016) and a co-author of Tasks for Part 3 MRCOG Clinical Assessment (2018). Bid also works for the National Guideline Alliance (NICE) as a topic lead for the review of many obstetric guidelines.

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Andrew Sizer Andrew Sizer is a Consultant Obstetrician and Gynaecologist at the Shrewsbury and Telford Hospital NHS Trust and Senior Lecturer at Keele University School of Medicine. He is currently RCOG College Tutor for the Trust and Undergraduate Lead for Women’s Health at the Shropshire campus for Keele University. Within the Postgraduate School of Obstetrics and Gynaecology in Health Education England, West Midlands, he is the Chair of Intermediate Training (ST3–5). He is the immediate past Chair of the Part 1 MRCOG examination committee and is current Chair of the standard setting committee and Honorary Deputy Director of Conferences at the RCOG. He was an examiner for the Part 2 MRCOG OSCE and is a current examiner for the Part 3 MRCOG clinical assessment. He is the lead author of two existing books for MRCOG examination preparation: SBAs for the Part 1 MRCOG (2012) and Part 2 MRCOG: Single Best Answer Questions (2016). He is also the developer of the andragOG.co.uk website, where a variety of other questions in a similar format are available.

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Author profiles

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The authors would like to acknowledge the contribution of Mr Sujeewa Fernando, Consultant Obstetrician and Gynaecologist, Wrexham Maelor Hospital, to the questions included in module 18. We would also like to thank the following doctors for being our ‘proofreaders’ during the first drafts of the manuscript and for their useful feedback: Dr Joanne Ritchie MRCOG, Dr Banchhita Sahu MRCOG, Dr Michael Algeo MRCOG, Dr James Castleman MRCOG, Dr Hector Georghiu MRCOG and Dr Pedro Melo MRCOG.

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Acknowledgements

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0.35–5.5 mU/l 11–24 pmol/l 1–11 IU/l 2–13 IU/l 0.5–3.0 nmol/l 8–30 nmol/l 0–520 mU/l 0.5–6.5% 18–144 nmol/l

Cancer antigen 125 (CA125):

0–35 IU/ml

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Please note: normal ranges can vary among laboratories.

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Endocrine Thyroid-stimulating hormone (TSH): Free T4: Follicle-stimulating hormone (FSH): Luteinising hormone (LH): Testosterone (female): Testosterone (male): Prolactin: Free androgen index: Sex hormone-binding globulin:

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35–50 g/l 0–22 μmol/l 40–130 IU/l 0–40 IU/l 0–75 U/l 0–14 μmol/l

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135–145 mmol/l 3.5–5.2 mmol/l 2.5–7.0 mmol/l 60–120 μmol/l

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Liver function Albumin: Total bilirubin: Alkaline phosphatase: Alanine aminotransferase (ALT): γ-Glutamyl transferase: Bile acids:

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Clinical chemistry Sodium: Potassium: Urea: Creatinine:

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eb 115–160 g/l 37–47% 4.0 × 109–11.0 × 109/l 150 × 109–400 × 109/l

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Haematology Haemoglobin (female): Haematocrit (female): Total white cell count: Platelets:

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Normal ranges (non-pregnant) used in the MRCOG

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International Federation of Gynecology and Obstetrics FSH follicle-stimulating hormone FSRH Faculty of Sexual and Reproductive Healthcare GBS group B Streptococcus GnRH gonadotropin-releasing hormone GTG Green-top Guideline HAART highly active antiretroviral treatment HBV hepatitis B virus hCG human chorionic gonadotropin HELLP haemolysis, elevated liver enzymes and low platelets HFEA Human Fertilisation and Embryology Authority HIV human immunodeficiency virus HRT hormone replacement therapy HSDD hypoactive sexual desire disorder HSG hysterosalpingogram HyCoSy hystero-contrastsalpingography IAP intrapartum antibiotic prophylaxis ICSI intracytoplasmic sperm injection IGFBP-1 insulin-like growth factorbinding protein-1 IUCD intrauterine contraceptive device IVF in vitro fertilisation LAM lactational amenorrhoea method LAVH laparoscopic-assisted vaginal hysterectomy LDH lactate dehydrogenase

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xvii

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FIGO

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ACE angiotensin-converting enzyme AED anti-epileptic drug AFP α-fetoprotein ALT alanine transaminase AMH anti-Müllerian hormone ARB angiotensin-receptor blocker AREDV absent or reversed enddiastolic velocity BASHH British Association for Sexual Health and HIV BAUS British Association of Urological Surgeons BHIVA British HIV Association BMI body mass index bpm beats per minute CBT cognitive behavioural therapy cCTG computerised CTG CEA carcinoembryonc antigen CI confidence interval COCP combined oral contraceptive pill CRP C-reactive protein CT computerised tomography CTG cardiotocograph CTPA computed tomography pulmonary angiography CXR chest X-ray DCDA dichorionic diamniotic DKA diabetic ketoacidosis DVT deep vein thrombosis EFW estimated fetal weight EMQ extended matching question ESHRE European Society of Human Reproduction and Embryology FBC full blood count FBS fetal blood sampling FGM female genital mutilation

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Abbreviations

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PCOS PE PET

polycystic ovarian syndrome pulmonary embolism positron emission tomography PGE2 prostaglandin E2 PID pelvic inflammatory disease PPROM preterm prelabour rupture of membranes PTS post-thrombotic syndrome PTSD post-traumatic stress disorder PUQE pregnancy-unique quantification of emesis RCOG Royal College of Obstetricians and Gynaecologists RMI risk of malignancy index RCVS reversible cerebral vascoconstriction syndrome SBA single best answer SGA small for gestational age ST speciality trainee STV short-term variation TCRE transcervical resection of the endometrium TENS transcutaneous electrical nerve stimulation TTP thrombotic thrombocytopenic purpura TTTS twin-to-twin transfusion syndrome U&E urea and electrolytes UDCA ursodeoxycholic acid UKMEC UK Medical Eligibility Criteria for Contraceptive Use UTI urinary tract infection V/Q ventilation/perfusion VBAC vaginal birth after a caesarean VIN vulval intraepithelial neoplasia VTE venous thromboembolism WPBA workplace-based assessment WHO World Health Organization

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LFT liver function test LH luteinising hormone LMWH low-molecular-weight heparin LNG-IUS levonorgestrel-releasing intrauterine system MBRRACE Mothers and Babies: Reducing Risk through Audits and Confidential Enquiries MCA middle cerebral artery MCDA monochorionic diamniotic MOGCT malignant ovarian germ cell tumour MPA medroxyprogesterone acetate MRKH Mayer–Rokitansky–Kuster– Hauser MRI magnetic resonance imaging MRSA methicillin-resistant Staphylococcus aureus NAAT nucleic acid amplification test NCEPOD National Confidential Enquiry into Patient Outcome and Death NHSLA National Health Service Litigation Authority NICE National Institute for Health and Care Excellence NSAID non-steroidal antiinflammatory drug NVP nausea and vomiting in pregnancy OASIS obstetric anal sphincter injuries OHSS ovarian hyperstimulation syndrome OR odds ratio PAEC progesterone receptor modulator-associated endometrial changes PAMG-1 placental α-microglobulin-1 PCA patient-controlled analgesia PCO2 partial pressure of carbon dioxide

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Abbreviations

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Membership of the Royal College of Obstetricians and Gynaecologists (MRCOG) is an essential component of specialist training in obstetrics and gynaecology in the UK. Possession of the MRCOG is also highly regarded by doctors working in other countries across the world, and many see the MRCOG as the ‘gold standard’ qualification in obstetrics and gynaecology. Worldwide, there are over 16,000 Fellows and Members of the RCOG.

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Format of the Part 2 MRCOG written examination

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We hope that our 500 questions give a broad coverage of the syllabus and that you will find the different styles of question writing useful. However, as obstetrics and gynaecology is such a vast subject, it is not possible for 500 questions to cover every facet of the specialty. Core modules 4 and 19 are not covered by the Part 2 examination so no questions on these two modules have been included. Different modules cover different proportions of the curriculum. The two biggest modules in terms of subject area are antenatal care and gynaecological problems. These modules therefore have the greatest number of questions in the book, with other modules appropriately weighted according to their size. We hope you find this book helpful as part of your examination preparation.

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Using this book

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The Part 2 examination consists of two written papers with a short break (approximately 30–60 minutes) between them. The two papers are identical in format and carry the same number of marks. Each paper consists of 50 SBAs and 50 EMQs, but the weighting of the two question types is different, with the SBA component being worth 40% of the marks and the EMQ component 60%. Each paper is of 3 hours’ duration, but in view of the weighting, the RCOG recommends that candidates spend approximately 70 minutes on the SBA component and 110 minutes on the EMQ component. The only time warnings are 30 minutes and 10 minutes before the end of the examination, so candidates must take responsibility for their own time management. Candidates must also remember to allow enough time to transfer their answers onto the computer marking sheets, as there is no extra time to do this. Traditionally, one paper is mainly obstetrics and the other mainly gynaecology, but there is no guarantee that this is this case, and, theoretically, any type of question or subject could appear in either paper.

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Introduction

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SBAs

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Clinical skills

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1

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Module

4.3 mmol/l

Creatinine

100 μmol/l

sf re

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m

What would be the most appropriate agent for electrolyte replacement therapy? Intravenous potassium chloride 0.3% with glucose 5% solution Intravenous potassium chloride 0.1% with sodium chloride 0.45% solution Intravenous potassium chloride 0.3% with sodium chloride 0.9% solution Oral potassium bicarbonate 500 mg with potassium acid tartrate 300 mg Oral potassium chloride 600 mg tablets

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A. B. C. D. E.

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Urea

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3.0 mmol/l

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130 mmol/l

Potassium

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Sodium

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1. A 28-year-old woman is admitted to the gynaecology ward with persistent nausea and vomiting in early pregnancy. Her serum urea and electrolytes are as follows:

30

120

5

29

111

29

150

29

111

7.5

2

10

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1

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5

150

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145

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7.5

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2

7.7

140

m

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111

136

re

E

Chloride

29

e. n

D

Bicarbonate

2

t

C

Calcium

5

ne

B

Potassium

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131

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m

Sodium A

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eb

2. What are the constituents of a litre of Hartmann’s solution (in mmol)?

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Module 1

2

C

✓

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re e

✓

✓ ✓

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et

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e. ne

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t

t

m

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eb

eb

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4. A 32-year-old multiparous woman has undergone an elective caesarean section under spinal anaesthesia at term. The spinal anaesthetic included intrathecal morphine. What is the minimum regime of postoperative clinical observations required for this woman? A. Continue observations every 30 minutes for 2 hours B. Continue observations every 30 minutes for 6 hours C. Continue observations every hour for 12 hours D. Continue observations every hour for 24 hours E. Continue observations every hour for 36 hours

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5. Each year, there are approximately 700,000 deliveries in England and Wales. What proportion of these women will have undergone female genital mutilation (FGM)? A. 0.1% B. 1.5% C. 3% D. 4.5% E. 6%

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✓

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E

m

✓

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D

Vancomycin

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✓

B

Teicoplanin

eb

✓

Metronidazole

m

✓

A

m

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Clindamycin

eb

Cefuroxime

m

eb

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3. A 34-year-old woman is admitted for an elective caesarean section. The woman is a known carrier of methicillin-­resistant Staphylococcus aureus (MRSA). Which are the most appropriate prophylactic antibiotics to use in this situation?

250 in 1000

C

10 in 1000

D

7.5 in 1000

E

5 in 1000

F

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0.2 in 1000

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J

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0.5 in 1000

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1 in 1000

I

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2 in 1000

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Each of the following clinical scenarios relates to the process of consenting for a treatment procedure. For each patient, select the single most appropriate option from the list above. Each option may be used once, more than once or not at all.

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2–3 in 1000

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B

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500–750 in 1000

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A

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Options for questions 6–8

3

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EMQs

Clinical skills

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6. A 29-year-old woman attends the gynaecology clinic wishing to discuss laparoscopic sterilisation as she wants a permanent method of contraception. During counselling, she enquires about the risk of a serious complication.

8. A couple attend the clinic to discuss permanent methods of contraception. The woman is aged 35 years, has a body mass index (BMI) of 37 kg/m2 and has had two caesarean sections. Her husband is aged 38 years. The woman is concerned about her risk of laparoscopic complications and wants her husband to consider a vasectomy. He enquires about the chance of late contraceptive failure after clearance for sterility is given following the vasectomy.

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ks f

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7. A junior specialty trainee is about to see a 30-year-old woman who wishes to be sterilised. Only Filshie clips are used for sterilisation in the unit where he works. What is the failure rate that should be quoted?

C

Cefalexin 500 mg orally every 8 hours

D

Ceftriaxone 2 g intravenous once daily

E

Clindamycin 900 mg intravenous every 8 hours

F

Co-amoxiclav 625 mg orally every 8 hours

G

Does not need antibiotic treatment

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t

m

m

t

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Gentamicin 4 mg/kg intravenous in three divided doses

sf re

Tetracycline 250 mg orally four times a day Trimethoprim 200 mg orally twice daily

Vancomycin 1 g intravenous every 12 hours

M

Vancomycin 250 mg orally four times a day

eb

eb

e. ne

e. ne

t

t

m

m

Each of the following clinical scenarios relates to the choice of management for the prophylaxis or treatment of infection. For each patient, select the single most appropriate management from the list above. Each option may be used once, more than once or not at all.

re e. n

ks f

fre

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9. A 24-year-old multiparous woman is in labour at 38 weeks’ gestation. A high vaginal swab taken at 23 weeks of gestation grew group B Streptococcus in culture. She is severely allergic to penicillin.

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L

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sf

K

Metronidazole 500 mg intravenous every 8 hours

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J

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Benzylpenicillin 3 g initially followed by 1.5 g 4 hourly

I

m

ks

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Amoxicillin 500 mg orally every 8 hours

B

eb

A

H

fre

re

m

eb

oo

ks f

Options for questions 9 and 10

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fre e. ne t

e. ne t

Module 1

4

eb oo

e. fre ks oo eb e.

ne t

m et e. n

e.

ne

t

m

m

eb

eb

oo

oo k

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sf

re

re e.

ne

ne

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m

m

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ks

ks

10. A 67-year-old woman has been under treatment with various antibiotics for prolonged periods due to recurrent pneumonia. She now presents with diarrhoea and her stool culture has grown Clostridium difficile.

e. ne t

oo

ks

oo ks

eb

eb

1. Answer  C  Intravenous potassium chloride 0.3% with sodium chloride 0.9% solution Explanation Oral preparations are unsuitable in the given circumstances. Option B has a very low concentration of potassium unsuitable for treatment of hypokalaemia. Option A contains glucose, and glucose infusions should not be used because they can cause a further decrease in the plasma potassium concentration.

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ks fre

re e

Reference

sf

British National Formulary, 72. September 2016–March 2017.

oo k

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Explanation Hartmann’s solution is one of the commonest intravenous infusions used in dayto-day practice on the ward. All grades of doctors must know its composition.

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m

m

eb

eb

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2. Answer  A  Sodium 131 mmol, potassium 5 mmol, calcium 2 mmol, bicarbonate 29 mmol, chloride 111 mmol

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t

t

m

m

m

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SBAs

5

fre

fre e. ne t

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Answers

Clinical skills

Reference

et re e. n

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t

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British National Formulary, 72. September 2016–March 2017.

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fre

3. Answer  D  Teicoplanin and vancomycin

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Reference

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British National Formulary, 72. Bacterial infection. September 2016–March 2017.

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4. Answer  D  Continue observations every hour for 24 hours

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eb

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Explanation Since 2008, it has been estimated that 1.5% of women each year giving birth in England and Wales have undergone FGM.

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et

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Hussain S, Rymer J. Tackling female genital mutilation in the UK. The Obstetrician & Gynaecologist 2017;19:273–8.

ne t

Reference

e.

eb

m

ks

ks f

oo k

sf

NICE. Caesarean section. NICE Clinial Guideline (CG 132). November 2011.

5. Answer  B 1.5%

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fre

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Reference

e.

re e.

ne

t

e. ne t

Explanation For women who have had intrathecal opioids, there should be a minimum hourly observation of respiratory rate, sedation and pain scores for at least 12 hours for diamorphine and 24 hours for morphine.

ne

eb

m

ks

ks

Explanation For MRSA carriers, teicoplanin or vancomycin should be used.

oo

ks

oo ks

eb

eb

Explanation Serious risks of laparoscopy include the overall risk of serious complications from diagnostic laparoscopy, which occur in approximately two women in every 1000.

m

m

eb

oo

6. Answer  G  2 in 1000

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fre

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EMQs

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Module 1

6

7. Answer  F  2–3 in 1000

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oo k

eb

eb

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Explanation Individuals should be informed that a vasectomy has an associated failure rate and that pregnancy can occur several years after vasectomy. The contraceptive failure rate should be quoted as approximately 1 in 2000 (0.05%) after clearance has been given.

m

m

m

eb

oo k

sf

8. Answer  I  0.5 in 1000

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t

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Explanation The longest period of available follow-­up data for the most commonly used method in the UK, the Filshie clip, suggests a failure rate of 2–3 in 1000 procedures at 10 years.

References

et re e. n

e. ne

e. ne

t

t

FSRH. Male and female sterilisation, FSRH Clinical Guidance. September 2014. RCOG. Diagnostic laparoscopy. RCOG Consent Advice No. 2. June 2017.

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fre

9. Answer  L  Vancomycin 1 g intravenous every 12 hours

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eb oo

oo

eb

Reference

m

m

m

eb

oo

ks

ks

Explanation Provided a woman has not had a severe allergy to penicillin, a cephalosporin should be used. If there is any evidence of a severe allergy to penicillin, vancomycin should be used.

t

t

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RCOG. Prevention of early-­onset neonatal group B streptococcal disease. RCOG GTG No. 36. September 2017.

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ne t

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ne

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British National Formulary, 72. Infection. September 2016–March 2017.

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sf

Reference

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Explanation For C. difficile infection, oral administration of vancomycin is more effective.

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ne

10. Answer  M  Vancomycin 250 mg orally four times a day

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eb

m

m

✓

t ne e.

fre ✓ ✓

7

ne t

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et

m

m t ne e.

ks

✓

e.

E

✓

oo

ks f ✓

D

eb

oo k

oo

✓

sf C

Does

eb

✓

✓

ne

✓

B

Shows how

re e.

Knows how

re

Knows

m

eb

t

e. ne t

13. Which two tiers of Miller’s pyramid are best assessed using workplace-­based assessment tools?

A

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ks

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t

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12. The SBAR format is commonly used on the delivery suite as a method to convey critical clinical information between different healthcare professionals. An ST5 telephones the consultant on call with the following communication. ‘Good evening, Dr Smith. This is John, the ST5, calling from the delivery suite. I have just been to see Mrs Jones who is in labour. The CTG is pathological. This woman is being monitored because of a previous stillbirth. I propose to take her to theatre for an immediate caesarean section.’ What component of SBAR is missing from this communication? A. Achievement B. Action C. Alignment D. Alternatives E. Assessment

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e. ne t

sf re

m

m

eb

eb

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sf

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11. In medical teaching, what is the single best determinant of expertise in a subject? A. Communication skills B. Knowledge C. Organisational skills D. Positive role modelling E. Technical ability

oo k eb

m

m

fre

t e. ne

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re e

SBAs

ks

m

m

eb

eb

oo

oo ks

Teaching and assessment

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2

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m

eb

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Module

fre

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m

m

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eb

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14. Which learning method is associated with the lowest retention of knowledge/ information imparted? A. Lecture B. Practical demonstration C. Problem-based learning D. Reading a textbook E. Small group discussion

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m

e. ne t

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e. ne t

Module 2

8

e. ne t

sf re

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eb

et re e. n ks f eb oo e. fre ks oo eb e.

ne t

m et e. n

e.

ne

t

m

m

eb

eb

oo

oo k

ks f

sf

re

re e.

ne

ne

t

t

e. ne t

m

m

m

eb

eb

oo

oo

ks

ks

fre

fre

e. ne

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t

t

m

m

m

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sf

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t

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15. What is the only type of workplace-­based assessment that has a summative role in obstetrics and gynaecology training? A. Case-based discussion B. Mini-Clinical Examination (Mini-CEX) C. Objective Structured Assessment of Technical Skills (OSATS) D. Reflective writing E. Team observation form

B

Appraisability

C

Appraisal

D

Assessment

E

Construct validity

Feasibility

K

Feedback

L

Formative assessment

M

Reliability

N

Sensitivity

O

Specificity

P

Summative assessment

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t

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e. ne

Validity

e. ne

t

m

eb

eb

oo

J

sf re

Face validity

oo k

Evaluation

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Educational impact

I

Q

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t e. ne

Content validity

H

sf oo k eb

m

m

m

t

re e

G

9

oo

Acceptability

eb

A

.n e

m

eb

oo

Options for questions 16–18

oo ks

ks f

EMQs

F

e. ne t

fre e. ne t

e. ne t re

Teaching and assessment

ks f

eb oo

oo

eb

16. The most important criterion for a quality assessment in medical education. 17. Pendleton’s rules provide a model of delivering this kind of activity in medical education.

m

m

m

eb

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ks

ks

fre

fre

The option list above relates to concepts, measurements and activities in medical education. For each of the following descriptions, what is the single most appropriate activity, measurement or concept that is being described? Each option may be used once, more than once or not at all.

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ks f

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eb

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m t ne e.

ne

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re sf oo k eb

m

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e. ne t

18. An activity that considers personal and educational development and is not measured against any set criteria.

C

Circular questioning

D

Crossover groups

E

Fishbowls

F

Group round

G

Horseshoe groups

eb m

m

e. ne

e. ne t

t

t .n e

Spiral groups

sf re

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Snowball groups

sf

J

Problem-based learning

re e

I

oo

Case-illustrated learning

ks

oo ks

Buzz groups

B

eb

A

H

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m

eb

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Options for questions 19 and 20

e. ne t

fre e. ne t

e. ne t

Module 2

10

oo k

eb

eb

m

m

19. The group is split into two, comprising an outer circle and an inner group. The outer circle members observe the inner group in the discussions in order to provide feedback.

et

t

t

m

eb

oo

oo k

The option list above relates to methods of small group teaching. For each of the following descriptions, what is the single most appropriate small group teaching method that is being described? Each option may be used once, more than once or not at all.

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ks f eb oo e. fre ks oo eb e.

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m et e. n

e.

ne

t

m

m

eb

eb

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sf

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re e.

ne

ne

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m

m

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eb

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oo

ks

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e. ne

20. The group is split into pairs and given a question or topic. Pairs combine to make a four, and then again to make an eight. The topics get more complex, and the groups of eight then feedback to the whole group.

11. Answer   B Knowledge

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11

ks eb

eb

oo

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SBAs

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ks f

Answers

eb

e. ne t

fre e. ne t

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Teaching and assessment

Reference

sf re

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Explanation The SBAR format (situation, background, assessment, recommendation) is also of use in transmitting critical information and is now commonplace on many delivery suites: Situation: Good evening, Dr Smith. This is John, the ST5, calling from the delivery suite. I have just been to see Mrs Jones who is in labour. The CTG is pathological. Background: This woman is being monitored because of a previous stillbirth. Assessment: None. Recommendation: I propose to take her to theatre for an immediate caesarean section.

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Reference

Jackson KS, Hayes K, Hinshaw K. The relevance of non-­technical skills in obstetrics and gynaecology. The Obstetrician & Gynaecologist 2013;15:269–74.

13. Answer   E  ‘Shows how’ and ‘Does’

ks

ks f

fre

e.

re e.

re sf

Reference

eb e.

ne t

m et e. n

e.

ne

t

m

m

eb

oo

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Parry-Smith W, Mahmud A, Landau A, Hayes K. Workplace-based assessment: a new approach to existing tools. The Obstetrician & Gynaecologist 2014;16:281–5.

eb

oo k

ne

ne

t

e. ne t

Explanation As the model for progression to mastery of a skill is sought, assessment is tailored to examine each of the pyramid’s levels: Knows (knowledge), Knows how (competence), Shows how (performance) and Does (action). It has been suggested that WPBA assesses the top two levels of the pyramid: performance and action.

t

m

m

eb

eb

m

ks

ks

fre

fre

e. ne

e. ne

t

t

m

m

m

eb

eb

oo k

12. Answer   E Assessment

oo k

sf

ks fre

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Duthie SJ, Garden AS. The teacher, the learner and the method. The Obstetrician & Gynaecologist 2010;12:273–80.

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e. ne

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t

t

m

m

m

Explanation Knowledge is the single best determinant of expertise in a subject. However, a practising obstetrician and gynaecologist also requires skills in communication, organisational ability, technical ability and teaching skills, as well as displaying the right attitude, to make them a good role model.

e. ne t ks oo eb

eb

Reference

Duthie SJ, Garden AS. The teacher, the learner and the method. The Obstetrician & Gynaecologist 2010;12:273–280

m

m

m

eb

oo

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Explanation Lectures result in only 5% retention.

fre

re

ks f

14. Answer   A Lecture

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e. ne t

Module 2

12

e. ne t

t

t

15. Answer   C  Objective Structured Assessment of Technical Skills (OSATS)

sf

Reference

sf re

ks fre

re e

e. ne

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Explanation All workplace-­based assessments have a formative role. Only OSATS have a summative role.

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eb

16. Answer   Q Validity

m

m

m

eb

EMQs

eb

oo

oo k

Parry-Smith W, Mahmud A, Landau A, Hayes K. Workplace-based assessment: a new approach to existing tools. The Obstetrician & Gynaecologist 2014;16:281–5.

fre

fre

17. Answer   K Feedback

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re e. n

e. ne

e. ne

t

t

Explanation Validity is the most important criterion of a quality assessment, i.e. the extent to which the assessment measures what it is intended to measure.

ks f

eb oo

eb

m

m

18. Answer   C Appraisal

Explanation Appraisal considers personal development as well as educational development and is not measured against any set criteria, nor does it contribute to a formal summative assessment. Appraisal is jointly developed by the trainee and trainer, and should be confidential and non-threatening.

ne e.

re

Reference

fre

re e.

ne

t

t

e. ne t

m

eb

oo

oo

ks

ks

Explanation The two most widely accepted models of delivering feedback are Pendleton’s rules and Silverman’s agenda-­led, outcome-­based analysis. Both models provide a safe environment, thus reducing defensiveness and increasing constructiveness.

ks

oo eb e.

ne t

m et e. n

e.

ne

t

m

m

eb

eb

oo

oo k

ks f

sf

Shehmar M, Khan KS. A guide to the ATSM in Medical Education. Article 2: assessment, feedback and evaluation. The Obstetrician & Gynaecologist 2010;12:119–25.

e. ne t

fre e. ne t

e. ne t ks f

19. Answer   E Fishbowls

13

fre

re

Teaching and assessment

oo

ks

oo ks

eb

m

m

m

eb

eb

oo

Explanation The usual fishbowl configuration has an inner group discussing an issue or topic while the outer group listens, looking for themes, patterns or soundness of argument, or uses a group behaviour checklist to give feedback to the group on its functioning. The roles may then be reversed.

20. Answer   I  Snowball groups

e. ne t

sf re

m

m

eb

Reference

m

oo k

oo

eb

eb

oo k

sf

ks fre

re e

e. ne

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t

t

Explanation Snowball groups (or pyramids) are an extension of buzz groups. Pairs join up to form fours, then fours to eights. These groups of eight report back to the whole group. This developing pattern of group interaction can ensure comprehensive participation, especially when it starts with individuals writing down their ideas before sharing them. To avoid students becoming bored with repeated discussion of the same points, it is a good idea to use increasingly sophisticated tasks as the groups gets larger.

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m et e. n

e.

ne

t

m

m

eb

eb

oo

oo k

ks f

sf

re

re e.

ne

ne

t

t

e. ne t

m

m

m

eb

eb

oo

oo

ks

ks

fre

fre

e. ne

e. ne

t

t

Jaques D. Teaching small groups. British Medical Journal 2003;326:492–4.

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eb

m

m

m

m

eb

eb oo

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e. ne

fre

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fre

ks

22. What type of consent is required for medical students performing pelvic examinations on anaesthetised women? A. Consent from the consultant responsible for the patient B. Formal consent is not required as this is part of clinical care C. Verbal consent from the woman D. Verbal consent witnessed by a member of the theatre staff E. Written consent

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m

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ne e.

14

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ne

t

e. ne t

23. A pregnant woman attends the accident and emergency department with abdominal pain and vaginal bleeding. It is 7 weeks since her last menstrual period. She subsequently becomes tachycardic and hypotensive, and collapses. Plans are made to take her to the operating theatre. As per the National Confidential Enquiry into Patient Outcome and Death (NCEPOD), which category of intervention would this be? A. 1 B. 2 C. 3 D. 4 E. U

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eb

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21. A 45-year-old woman is admitted to the gynaecology ward for a planned hysterectomy for endometrial hyperplasia with atypia. A pregnancy test has not been carried out prior to theatre, and during the course of the laparotomy a mass is detected in the right fallopian tube that has an appearance suggestive of an unruptured ectopic pregnancy. A catheter specimen of urine is then used to perform a pregnancy test, which is found to be positive. What would be the correct course of action? A. Contact a colleague for a second opinion B. Contact the patient’s partner for authorisation C. Continue with the hysterectomy including removal of the right tube D. Remove the right fallopian tube for histological confirmation E. Stop the surgery and reschedule

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SBAs

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IT, clinical governance and research t

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eb

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3

fre e. ne t

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ks f

Module

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eb

m

15

ks

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24. How many principal steps are there in an audit cycle? A. 3 B. 4 C. 5 D. 6 E. 7

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m

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IT, clinical governance and research

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t

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25. Which phase of a clinical trial compares a new treatment with the current best available treatment? A. 0 B. I C. II D. III E. IV

B

Anaesthetic complications

C

Cardiac disease

D

Early pregnancy complications

E

Haemorrhage

F

Malignancy

Venous thromboembolism

sf re

Suicide

K

eb

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J

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t e. ne

Sepsis

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Pre-eclampsia

I

sf

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t

Neurological disease

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From the list of options above, choose the single most appropriate cause of maternal death as published in the MBRRACE (Mothers and Babies: Reducing Risk through Audits and Confidential Enquiries) report of 2016. Each option may be chosen once, more than once or not at all.

re e. n

e. ne

e. ne

26. The leading cause of indirect maternal death.

et

t

t

m

oo

Amniotic fluid embolism

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A

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Options for questions 26 and 27

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ks f

EMQs

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fre e. ne t

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Module 3

16

ks f eb oo e. fre ks oo eb e.

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m et e. n

e.

ne

t

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m

eb

eb

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m

m

m

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ks

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27. The leading cause of direct maternal death occurring within a year of the end of pregnancy.

C

High-risk case review

D

Refer case to Caldicott guardian

E

Refer concerns to Medical Director

F

Refer to coroner

G

Refer to multidisciplinary team meeting

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eb

m

m

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e. ne t

t

t

Reflective entry in portfolio Serious incident review Service evaluation

K

Team debriefing session

L

Undertake root cause analysis

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J

sf re

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fre ks

Audit

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From the list of options above related to clinical governance, choose the single most appropriate initial course of action for each of the following scenarios. You may choose an option once, more than once or not at all.

re e. n

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t

t

28. A specialty trainee is collecting data for a research project. She has scanned copies of the patients’ notes and saved these on an unencrypted memory stick. When she arrives home one evening, she cannot find the memory stick.

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17

oo

Arrange meeting with Trust lawyer

B

I

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A

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Options for questions 28–30

H

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IT, clinical governance and research

eb

eb oo

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30. A woman is admitted for a planned caesarean section. During the course of the operation, she has a cardiac arrest and it is not possible to resuscitate her. She is thought to have had an amniotic fluid embolism.

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29. A fetal medicine specialist performs an amniocentesis at 17 weeks of gestation. Two days later, the woman has a miscarriage. The midwives feel that the particular specialist has a high miscarriage rate following antenatal invasive tests.

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SBAs

ks

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Answers

e. ne t

fre e. ne t

e. ne t

Module 3

18

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eb

Explanation A potentially viable pregnancy should not be terminated without the woman’s consent and following the processes outlined in the 1967 Abortion Act. If a pregnancy is discovered at the start of a hysterectomy, including one for cancer, the operation should be rescheduled. An unexpected ectopic pregnancy should be removed. It is reasonable to presume that the woman would wish this and would wish the surgeon to act in favour of lifesaving treatment.

e. ne t

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Explanation Explicit consent of women is required for the presence of students: • During gynaecological and obstetric consultations • In operating theatres as observers and assistants • When performing a clinical pelvic examination. Written consent must be obtained for pelvic examination of anaesthetised women.

re e. n

fre

fre

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t

t

m

m

Reference

1

Immediate

Minutes

Haemorrhage

Urgent

Hours

Expedited

Days

ne

Tendon injury Varicose veins

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Reference

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fre

Planned

e.

Fracture

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Elective

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4

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3

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Example

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m Time to theatre

t

Description

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Category 2

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ne

t

m

eb

eb

See the National Confidential Enquiry into Patient Outcome and Death (NCEPOD) website at www.ncepod.org.uk (accessed 25 July 2018).

m

eb

ks f

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eb

Explanation NCEPOD categories are:

m

m

eb

23. Answer   A  Category 1

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oo

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ks

RCOG. Obtaining valid consent. Clinical Governance Advice No. 6. 2015.

e.

m

eb

22. Answer   E  Written consent

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RCOG. Obtaining valid consent. Clinical Governance Advice No. 6. 2015.

sf re

sf

Reference

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re e

e. ne

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t

t

m

m

m

eb

21. Answer   C  Continue with the hysterectomy including removal of the right tube

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24. Answer   C 5

19

fre

re

IT, clinical governance and research

oo

ks

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eb

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ks fre

re e

Reference

sf re

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t

t

m

m

oo

Explanation Traditionally, to introduce a drug into clinical practice, it passes through four phases: • Phase I trials (20–80 people) to evaluate safety, determine a safe dosage range and identify side effects in a small group of people • Phase II trials (100–300 people) to evaluate safety and to begin to determine efficacy • Phase III trials (1000–3000 or more people if the chosen primary outcome measure has a low frequency, e.g. neonatal death) where it is compared to existing treatments • Phase IV postmarketing studies to delineate additional information, such as the treatment risks, benefits and optimal use.

eb

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eb oo

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Reference

eb

ks f

ks

oo

oo

ks

fre

fre

e. ne

e. ne

t

t

m

m

m

eb

eb

oo k

25. Answer   D III

oo k

sf

RCOG. Understanding audit. Clinical Governance Advice No. 5. 2003.

e.

fre

oo

oo

e.

ne t

m

et e. n

ne

t

m

eb

eb

Explanation The rate of maternal death by suicide remains unchanged since 2003, and maternal suicides are now the leading cause of direct maternal deaths occurring within a year after the end of pregnancy.

e.

eb

27. Answer  J Suicide

ks

ks f

oo k

sf

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re e.

Explanation As in previous reports, cardiac disease remained the largest single cause of indirect maternal deaths in 2012–14.

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26. Answer   C  Cardiac disease

t

t

e. ne t

m

m

m

RCOG. Developing new pharmaceutical treatments for obstetric conditions. Scientific Impact Paper No. 50. 2015.

EMQs

m

et

m

eb

eb

oo

Explanation An audit can be considered to have five principal steps, commonly referred to as the audit cycle (see Figure 1 in the reference article): 1. Selection of a topic. 2. Identification of an appropriate standard. 3. Data collection to assess performance against the prespecified standard. 4. Implementation of changes to improve care if necessary. 5. Data collection for a second, or subsequent, time to determine whether care has improved.

28. Answer   D  Refer case to Caldicott guardian

sf

Reference

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t

t

Explanation The Caldicott guardian is responsible for all breaches of personal data within a hospital Trust and should be informed immediately in such a case. Subsequent actions may include a serious incident review.

e. ne t

m

m

eb

eb

oo

ks

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Knight M, Nair M, Tuffnell D, et al. (eds.) on behalf of MBRRACE-­UK. Saving Lives, Improving Mothers’ Care: Surveillance of Maternal Deaths in the UK 2012–14 and Lessons Learned to Inform Maternity Care From the UK and Ireland Confidential Enquiries into Maternal Deaths and Morbidity 2009–14. Oxford: National Perinatal Epidemiology Unit, University of Oxford, 2016.

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m

fre

re

ks f

Reference

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fre e. ne t

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Module 3

20

eb

eb

fre

fre

Reference

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m

eb

eb

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oo

ks

ks f

fre

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ne

ne

re e.

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sf

Reference

t

t

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m

m

eb

Explanation A doctor may report the death to a coroner if: • The cause of death is unknown • The death was violent or unnatural • The death was sudden and unexplained • The person who died was not visited by a medical practitioner during their final illness • The medical certificate is not available • The person who died was not seen by the doctor who signed the medical certificate within 14 days before death or after they died • The death occurred during an operation or before the person came out of anaesthetic • The medical certificate suggests that the death may have been caused by an industrial disease or industrial poisoning.

oo k

ne t e.

et e. n

ne

t

See the gov.uk website at www.gov.uk/after-a-death/when-a-death-is-reported-to-a-coroner (accessed 25 July 2018).

e.

eb

m

eb oo

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m

ks

ks

RCOG. Understanding audit. Clinical Governance Advice No. 5. 2003.

30. Answer   F  Refer to coroner

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e. ne

e. ne

t

t

m

m

Explanation Audit is a process whereby performance can be compared to a prespecified standard. All specialists will have some miscarriages after amniocentesis. An audit will determine if this doctor’s performance is at odds with the expected rate. The audit can be considered to have five principal steps, commonly referred to as the audit cycle (see answer to question 24 for details).

re e. n

eb

29. Answer   B Audit

m

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Roch-Berry C. What is a Caldicott guardian? Postgraduate Medical Journal 2003;79:516–18.

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e. ne t

t e. ne

sf re eb

m

m

eb

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sf

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31. Which absorbable suture has the greatest tensile strength? A. Polydiaxonone (PDS) B. Polyglactic 910 (Vicryl rapide) C. Polyglactin (Vicryl) D. Polyglecaprone (Monocryl) E. Polyglycolic acid (Dexon)

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SBAs

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Core surgical skills

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5

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Module

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21

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34. During a primary caesarean section, at what point during the operation is a bladder injury most likely to occur? A. Closure of the uterine incision B. Delivery of the baby C. Dissection of bladder from the lower segment D. During catheterisation E. Entry into the peritoneal cavity

m

eb

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33. Which nerve is particularly susceptible to damage when self-­retaining retractors are used in gynaecological surgery? A. Femoral nerve B. Genitofemoral nerve C. Iliohypogastric nerve D. Obturator nerve E. Pudendal nerve

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ks f

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32. What proportion of ureteric injuries are recognised intraoperatively during laparoscopic surgery? A. 10% B. 25% C. 33% D. 50% E. 67%

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35. Taking all surgical procedures into consideration, which organism is most commonly implicated in inpatient surgical-­site infections in England? A. Enterobacteriaceae B. Enterococcus spp. C. Methicillin-resistant Staphylococcus aureus (MRSA) D. Pseudomonas spp. E. Staphylococcus aureus

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39. What is the overall approximate risk of serious complications from an abdominal hysterectomy? A. 1 in 100 B. 2 in 100 C. 3 in 100 D. 4 in 100 E. 5 in 100

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m

m

eb

eb oo

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ks

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38. For an obese woman with no co-­morbidities who has been unsuccessful in reducing her weight with dietary modification and exercise, what is the threshold BMI where bariatric surgery should be considered? A. 32 kg/m2 B. 35 kg/m2 C. 38 kg/m2 D. 40 kg/m2 E. 45 kg/m2

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37. What proportion of women in the UK have a body mass index (BMI) of >30 kg/m2? A. 6% B. 11% C. 16% D. 21% E. 26%

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36. Urinary catheter size is identified by Charrière (Ch) or French gauge (Fg) or French (F). What does the gauge represent? A. External diameter B. Flow rate C. Internal diameter D. Length E. Volume of retaining balloon

e.

m

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Module 5

22

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fre

37°C

Pulse

110 beats per minute

Blood pressure

90/60 mmHg

Urine

Small volume of very dark urine

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Temperature

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Which is the most appropriate intravenous fluid to be used for immediate resuscitation? A. Albumin 5% B. Dextrose 5% C. Sodium chloride 0.9% D. Sodium chloride 0.18%/4% glucose E. Sodium chloride 0.45%/4% glucose

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fre

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42. A 49-year-old woman is admitted to the gynaecology ward following an episode of significant vaginal bleeding due to a uterine fibroid. On examination, she is pale, well oriented and conscious. The observations are:

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eb

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sf

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41. What is the most appropriate suture material to repair the anorectal mucosa in a fourth-­degree perineal tear? A. Polydiaxonone (PDS) B. Polyglactic 910 (Vicryl rapide) C. Polyglactin (Vicryl) D. Polyglecaprone (Monocryl) E. Polyglycolic acid (Dexon)

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23

40. A 45-year-old nulliparous woman who is otherwise fit and well attends for an outpatient hysteroscopy to investigate a potential polyp, which was suggested on an ultrasound scan. What pharmacotherapy would be recommended to reduce pain in the immediate postoperative period? A. Administration of a paracervical anaesthetic block B. Instillation of local anaesthetic gel into the cervical canal C. Oral non-­steroidal anti-­inflammatory drug (NSAID) an hour before the procedure D. Oral opiate analgesia 1 hour before the procedure E. Use of conscious sedation

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m

Core surgical skills

fre

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ks sf re

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eb

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m

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45. During primary entry with a force of 3 kg for gynaecological laparoscopy, what is the depth below the indented umbilicus with a peritoneal insufflation pressure of 25 mmHg? A. 18 cm

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m

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fre

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t

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sf

ks fre

re e

44. What is the risk of major vessel injury with the Hasson (open) technique of laparoscopic entry? A. 25 IU/l

re e.

297. Answer  

t

e. ne t

ESHRE. Management of women with endometriosis. ESHRE Guideline. September 2013.

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fre e. ne t

e. ne t

173

fre

re

D 60%

ks f

298. Answer  

Gynaecological problems

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m

m

Reference

m

ks

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eb

eb

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Explanation Ulipristal acetate use has been found to be associated with benign endometrial changes termed PAEC. These changes were noted in up to two-­thirds of women during treatment and resolved within 6 months of discontinuation of treatment.

E  Upper vagina

Reference

eb

eb

oo

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sf re

ks fre

re e

Explanation The incidence of this is unclear but is probably not greater than 1 in 30,000 to 1 in 50,000. The septae may occur anywhere along the length of the vagina, although they are classified as upper, mid- and lower, with the upper septae accounting for 46%, the mid-­vagina 30–40% and the lower vagina 15–20%.

sf oo k eb

e. ne t

299. Answer  

e. ne

.n e

t

t

Younas K, Hadoura E, Majoko F, Bunkheila A. A review of evidence-­based management of uterine fibroids. The Obstetrician & Gynaecologist 2016;18:33–42.

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et

t

t

D Oestrone

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300. Answer  

m

m

m

Edmonds DK, Rose GL. Outflow tract disorders of the female genital tract. The Obstetrician & Gynaecologist 2013;15:11–17.

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eb

m

Reference

t

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fre

m

m

eb

eb

oo

oo

ks

ks f

sf

re

re e.

ne

t

e. ne t

Explanation RMI is calculated as: RMI = U × M × CA125, where U = 0 (for an ultrasound score of 0), U = 1 (for an ultrasound score of 1) or U = 3 (for ultrasound score of 2–5); M = 3 for all postmenopausal women dealt with by this guideline; and CA125 is the serum CA125 measurement in IU/ml. Ultrasound scans score 1 point for each of the following characteristics: • Multilocular cyst • Evidence of solid areas • Evidence of metastases • Presence of ascites • Bilateral lesions.

ne

E

m

301. Answer  

ne t e.

et e. n

ne

t

RCOG. Ovarian cysts in postmenopausal women. RCOG GTG No. 34. July 2016.

e.

oo k eb

m

re e. n

Otify M, Fuller J, Ross J, Shaikh H, Johns J. Endometrial pathology in the postmenopausal woman – an evidence based approach to management. The Obstetrician & Gynaecologist 2015;17:29–38.

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m

ks

ks

Reference

ks f

fre

fre

Explanation In obese women, it is the increased circulating level of oestrone that is likely to be the cause of polyp development and growth.

m

m

eb

eb

oo

ks

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Explanation A woman with normal serum CA125 level (2 weeks has elapsed following a scan that showed a gestational sac without a yolk sac • Absence of an embryo with a heartbeat >11 days after a scan that showed a gestational sac and yolk sac.

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fre

ks

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eb

eb

m

m

Reference

t

t

ne

re e.

re

sf oo k

ne t e.

et e. n

ne

t

Al-Memar M, Kirk E, Bourne T. The role of ultrasonography in the diagnosis and management of early pregnancy complications. The Obstetrician & Gynaecologist 2015;17:173–81.

e.

eb

m

eb oo

eb

B  Missed miscarriage

m

394. Answer 

e. ne t

m

eb

oo

oo

ks

ks

Al-Memar M, Kirk E, Bourne T. The role of ultrasonography in the diagnosis and management of early pregnancy complications. The Obstetrician & Gynaecologist 2015;17:173–81.

e. ne t

fre e. ne t

e. ne t A  5% of prepregnancy weight, dehydration and electrolyte imbalances.

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m

ks

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ks f

400. Answer  B  Electrolyte imbalance, 5% weight loss from prepregnancy weight and dehydration

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et

t

t

e. ne

Reference

m

m

eb

eb

oo

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sf

Explanation In two-­thirds of patients with hyperemesis gravidarum, there may be abnormal thyroid function tests (based on a structural similarity between thyroid-­ stimulating hormone (TSH) and β-­hCG) with a biochemical thyrotoxicosis and raised free thyroxine levels with or without a suppressed TSH level. These patients rarely have thyroid antibodies and are euthyroid clinically. The biochemical thyrotoxicosis resolves as the hyperemesis gravidarum improves, and treatment with antithyroid drugs is inappropriate.

oo k eb

m

e. ne t

e. ne

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D 66%

re e

401. Answer 

t

t

RCOG. The management of nausea and vomiting of pregnancy and hyperemesis gravidarum. RCOG GTG No. 69. June 2016.

ks

ks

Explanation Previous reproductive history is an independent predictor of future pregnancy outcome. The risk of a further miscarriage increases after each successive pregnancy loss, reaching approximately 40% after three consecutive pregnancy losses, and the prognosis worsens with increasing maternal age. Reference

m

m

eb

eb oo

oo

oo eb

m

re e. n

C 60%

ks f

402. Answer 

fre

fre

RCOG. The management of nausea and vomiting of pregnancy and hyperemesis gravidarum. RCOG GTG No. 69. June 2016.

t fre

e.

ne

ne

re e.

A 2%

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403. Answer 

t

e. ne t

RCOG. The investigation and treatment of couples with recurrent first trimester and second-­trimester miscarriage. RCOG GTG No. 17. April 2011.

ks

oo

oo

eb

eb

Reference

e.

ne t

m

et e. n

ne

t

m

RCOG. The investigation and treatment of couples with recurrent first trimester and second-­trimester miscarriage. RCOG GTG No. 17. April 2011.

e.

m

eb

oo k

ks f

sf

Explanation A recent retrospective UK audit of four UK centres over periods of 5–30 years reported that balanced translocations were found in 1.99% (406 out of 20,432) of parents with recurrent miscarriage.

fre

oo

eb

m

m

m

221

ks

oo ks

eb

eb

oo

Explanation Several case series have shown that vaginal bleeding is the most common presenting symptom of gestational trophoblastic disease diagnosed after miscarriage, therapeutic termination of pregnancy or postpartum. Reference

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fre e. ne t

e. ne t re

E  Vaginal bleeding

ks f

404. Answer 

Early pregnancy care

RCOG. The management of gestational trophoblastic disease. RCOG GTG No. 38. March 2010.

sf re

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oo

eb

eb

Reference

ks f

C  Karyotyping of products of conception

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ks

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407. Answer 

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ks

fre

fre

Explanation Women with a second-­trimester miscarriage should be screened for inherited thrombophilias including factor V Leiden, factor II (prothrombin) gene mutation and protein S.

Explanation Cytogenetic analysis should be performed on the products of conception of the third and subsequent consecutive miscarriage(s).

ne e.

ks

ks f

oo

oo

Reference

fre

re

re e.

Explanation Recurrent miscarriage, defined as the loss of three or more consecutive pregnancies, affects 1% of couples trying to conceive. There is no need to investigate after two miscarriages.

sf

RCOG. The investigation and treatment of couples with recurrent first trimester and second-­trimester miscarriage. RCOG GTG No. 17. April 2011.

eb

e.

ne t

m et e. n

e.

ne

t

m

m

eb

oo k

t

D  No test required

ne

408. Answer 

t

e. ne t

m

m

m

eb

et

J  Thrombophilia screen

re e. n

406. Answer 

e. ne

e. ne

t

t

m

m

m

RCOG. The management of gestational trophoblastic disease. RCOG GTG No. 38. March 2010.

EMQs

eb

e. ne t

e. ne

ks fre

re e

Explanation Because of poor vascularisation of the chorionic villi and absence of the anti-­D antigen in complete moles, anti-­D prophylaxis is not required. It is, however, required for partial moles. Confirmation of the diagnosis of a complete molar pregnancy may not occur for some time after evacuation and so administration of anti-­D could be delayed when required, within an appropriate timeframe.

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t

t

C  Anti-­D is not required

.n e

405. Answer 

F  MRI scan

410. Answer 

re e

e. ne

.n e

t

t

Explanation MRI can be a useful diagnostic adjunct in advanced abdominal pregnancy and can help to plan the surgical approach. M  Transvaginal ultrasound scan

sf re

ks fre

411. Answer 

e. ne t

m

m

eb

eb

oo

ks

oo ks

Explanation Clinicians should be aware that ultrasound is the primary diagnostic modality, using a transvaginal approach, supplemented by transabdominal imaging if required.

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m

fre

re

M  Transvaginal ultrasound scan

ks f

409. Answer 

e. ne t

fre e. ne t

e. ne t

Module 16

222

eb

RCOG. Diagnosis and management of ectopic pregnancy. RCOG GTG No. 21. November 2016.

m

re e. n

ks f

eb oo

oo

eb

m

m

H  Laparoscopic salpingotomy

e.

fre

ks

oo

ne t

m

et

e. n

t

m

eb

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Explanation NICE recommends that methotrexate should be the first-­line management for women who are able to return for follow-­up and who have: • No significant pain • An unruptured ectopic pregnancy with a mass smaller than 35 mm with no visible heartbeat

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ne

ne

re e.

ks f

oo

F  Intramuscular methotrexate

e.

t

t

e. ne t

re

sf oo k eb

414. Answer 

e.

413. Answer 

Explanation A laparoscopic surgical approach is preferable to an open approach. In women with a history of fertility-­reducing factors (previous ectopic pregnancy, contralateral tubal damage, previous abdominal surgery, previous pelvic inflammatory disease), salpingotomy should be considered. Success rates for methotrexate are only 38% if β-­hCG levels are >5000 IU/l.

m

et

e. ne

ks

ks

fre

fre

Explanation Medical management with methotrexate can be considered for cervical pregnancy. Surgical methods of management are associated with a high failure rate and should be reserved for those women suffering life-­threatening bleeding. A retrospective review of 62 cases of cervical ectopic pregnancy estimated the efficacy of systemic methotrexate administration in the treatment of cervical ectopic pregnancy to be approximately 91%.

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t

t

F  Intramuscular methotrexate

e. ne

412. Answer 

m

oo k

oo

eb

Reference

m

m

eb

oo k

sf

Explanation A transvaginal ultrasound scan is the diagnostic tool of choice for tubal ectopic pregnancies.

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fre e. ne t

e. ne t

223

fre

re

Early pregnancy care

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eb

eb

eb

Reference

ks

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ks f

• A serum β-­hCG between 1500 and 5000 IU/l • No intrauterine pregnancy (as confirmed by an ultrasound scan). Expectant management is not appropriate as the serum β-­hCG level is rising.

415. Answer 

m

m

m

RCOG. Diagnosis and management of ectopic pregnancy. RCOG GTG No. 21. November 2016.

A 23,X

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K 69,XXY

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ks

ks

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3%

e. ne

27%

69,XYY

fre

69,XXX

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t

t e. ne

70%

fre

69,XXY

Reference

e.

re e.

Reference

ne

ne

t

e. ne t

This is likely to be a choriocarcinoma, and 50% of these tumours arise from a hydatidiform mole. The majority (90%) of hydatidiform moles have the karyotype 46,XX.

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D 46,XX

m

417. Answer 

eb

Nyberg DA, McGahan JP, Pretorius DH, Pilu G (eds.). Diagnostic Imaging of Fetal Anomalies. Philadelphia: Lippincott Williams & Wilkins, 2003.

m

eb

m

416. Answer 

eb

RCOG. The management of gestational trophoblastic disease. RCOG GTG No. 38. March 2010.

Explanation The frequencies of the karyotypes of partial moles are:

m

e. ne t

sf re

oo k

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Reference

m

m

eb

oo k

sf

ks fre

re e

e. ne

.n e

t

t

Explanation Complete moles usually (75–80%) arise as a consequence of duplication of a single sperm following fertilisation of an ‘empty’ ovum. Two Y chromosomes are not compatible with development, so as duplication is the most likely cause, the sperm must have been 23X.

fre

ks oo

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J 90%

Reference

m

m

eb

eb

Explanation Partial moles are usually (90%) triploid in origin, with two sets of paternal haploid genes and one set of maternal haploid genes.

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ne

t

RCOG. The management of gestational trophoblastic disease. RCOG GTG No. 38. March 2010.

e.

m

eb

oo k

418. Answer 

ks f

sf

re

Fox H, Buckley CH. Pathology for Gynaecologists. 2nd edn. London: Hodder Arnold, 1991.

A