(SAMPLE) 1- Early Pregnancy (SBA)

Question 1 A 47 year old woman with detrusor over-activity has been successfully treated with botulinum toxin A. Five months later, her symptoms recur Options for Questions 1-1

A Refer to the urogynaecology multi-disciplinary team B Offer repeat treatment with botulinum toxin A

C Offer treatment with anti-cholinergic drugs D Offer posterior tibial nerve stimulation E Offer treatment with botulinum toxin B

A(Correct answ er: B)

Explanation Repeat treatment

If botulinum toxin A treatment is effective, offer follow-up at 6 months or sooner if symptoms return for repeat treatment without an MDT referral Tell women how to self-refer for prompt specialist review if symptoms return.

Botulinum toxin B is not recommended for the treatment of women with idiopathic OAB

Question 2 A 67 year old woman is being treated with mirabegron for urinary incontinence. She has a history of cardiac disease treated with digoxin. Options for Questions 2-2

A Increase the dose of digoxin B Reduce the dose of digoxin C Increase the dose of mirabegron D Reduce the dose of mirabegron E Add aspirin to digoxin


Explanation Mirabegron - Drug interactions Clarithromycin Avoid or reduce dose of mirabegron in hepatic or renal impairment when given with clarithromycin Digoxin Mirabegron increases plasma concentration of digoxin reduce initial dose of digoxin Itraconazole Avoid or reduce dose of mirabegron in hepatic or renal impairment when given with itraconazole Metoprolol Mirabegron increases plasma concentration of metoprolol Ritonavir Avoid or reduce dose of mirabegron in hepatic or renal impairment when given with ritonavir

Question 3 The incidence of hyperemesis gravidarum is

Options for Questions 3-3

A 0.1 0.2 per 1000 pregnancies B 0.5 1.5 per 1000 pregnancies C 4 10 per 1000 pregnancies D 12 14 per 1000 pregnancies E 20 25 per 1000 pregnancies

A(Correct answ er: C)

Explanation HYPEREMESIS GRAVIDARUM

Vomiting severe enough to require hospital admission - associated with dehydration + weight loss of at least 3kg. Affects 3-10 women /1000 pregnancies Presents in first trimester and is unusual after 16 weeks gestation. Peak incidence 8-12 weeks Aetiology not fully understood but related to HCG and TSH levels +/- psychological factors. There is, however, no

direct relationship between the severity of the disorder and HCG or TSH levels An association exists with hyperthyroidism, pyridoxine deficiency, and psychological factors 50% recurrence rate Diagnosis of exclusion - UTI / Gastroenteritis / pancreatitis / peptic ulceration, hepatitis, diabetic ketoacidosis, acute

appendicitis should be considered Associated with metabolic alkalosis - hypochloraemic alkalosis with hypokalaemia and potassium loss in urine Urine is acidic despite systemic alkalosis - when alkalosis is associated with volume depletion, bicarbonate is not

excreted Excretion of bicarbonate only occurs with restoration of extracellular fluid volume

Question 4 The biochemistry of hyperemesis gravidarum is characterised by


A Metabolic acidosis and hypochloraemia B Metabolic alkalosis and hyperchloraemia C Hypokalaemia and hyperchloraemia D Hyperkalaemia and hypochloraemia E Metabolic alkalosis and hypochloraemia

A(Correct answ er: E)

Explanation HYPEREMESIS GRAVIDARUM

Vomiting severe enough to require hospital admission - associated with dehydration + weight loss of at least 3kg. Affects 3-10 women /1000 pregnancies Presents in first trimester and is unusual after 16 weeks gestation. Peak incidence 8-12 weeks Aetiology not fully understood but related to HCG and TSH levels +/- psychological factors. There is, however, no

direct relationship between the severity of the disorder and HCG or TSH levels An association exists with hyperthyroidism, pyridoxine deficiency, and psychological factors 50% recurrence rate Diagnosis of exclusion - UTI / Gastroenteritis / pancreatitis / peptic ulceration, hepatitis, diabetic ketoacidosis, acute

appendicitis should be considered Associated with metabolic alkalosis - hypochloraemic alkalosis with hypokalaemia and potassium loss in urine Urine is acidic despite systemic alkalosis - when alkalosis is associated with volume depletion, bicarbonate is not

excreted Excretion of bicarbonate only occurs with restoration of extracellular fluid volume

Question 5 A 17 year old woman has surgical evacuation of a molar pregnancy at 8 weeks gestation. Karyotype is reported as 46XX. The risk of her needing chemotherapy is Options for Questions 5-5

A 1-2% B 5-7% C 15-18% D 25-30% E 40-50%


Explanation Risk factors for malignant change / need for chemotherapy

Maternal age: 9 fold increase in risk in >40 years compared to 20-24 age group Initial method of evacuation: lowest risk after vacuum aspiration ABO blood group: highest risk in woman with blood group A and partner with blood group O; lowest risk in woman

with blood group A and partner with blood group A Complete or partial mole: malignant potential higher with complete mole: about 16% require chemotherapy compared

to 0.5%% after partial mole Post-evacuation contraception: COCP may be used even before HCG levels have returned to normal

Question 6 Factor V Leiden mutation is associated with


A Recurrent first trimester miscarriage B Pre-eclampsia C Placental abruption D Fetal growth restriction E Post-partum haemorrhage

A(Correct answ er: A)

Explanation Inherited thrombophilias

Include protein C / S and antithrombin III deficiency, activated protein C resistance (most commonly Factor V Leiden mutation), hyperhomocystinaemia, prothrombin gene and Methylenetetrahydrofolate mutation.

Factor V Leiden mutation is associated with recurrent first-trimester miscarriage, recurrent fetal loss after 22 weeks and non-recurrent fetal loss after 19 weeks

Activated protein C resistance is associated with recurrent first-trimester miscarriage. Prothrombin gene mutation is associated with recurrent first-trimester miscarriage, recurrent fetal loss before 25

weeks and late non-recurrent fetal loss. Protein S deficiency is associated with recurrent fetal loss and non-recurrent fetal loss after 22 weeks. Methylenetetrahydrofolate mutation and protein C and antithrombin deficiencies are not associated with fetal loss.

Protein C and antithrombin III deficiencies are rare.

Question 7 A 31 year old woman with an ectopic pregnancy has been treated with single dose methotrexate. The dose of methotrexate should be calculated based on Options for Questions 7-7

A The womans GFR B The womans body surface area C The womans BMI D The womans weight E The gestation age


Explanation Among women trying to become pregnant, intra-uterine pregnancy rate = 54% and recurrent ectopic rates = 8-10% - comparable to those following laparoscopic salpingostomy?? Intra-muscular methotrexate - dose calculated pre m2 body surface area (50mg/square m)??

Question 8 A 23 year old woman with epilepsy has been referred for antenatal care. She enquires about vitamin K supplementation. She needs vitamin K Options for Questions 8-8

A From 34 weeks if she is taking any anti-epileptic drugs B From 34 weeks regardless of whether she is taking any anti-epileptic drugs

C From 34 weeks if she is taking enzyme-inducing anti-epileptic drugs D From 34 weeks if she is taking more than one anti-epileptic drug

E At the time of delivery if she is taking enzyme-inducing anti-epileptic drugs


Explanation Maternal vitamin K supplementation from 34-36 weeks in women taking enzyme-inducing AEDs to reduce the risk of maternal and neonatal bleeding. May be oral or im

Question 9 With respect to Von Willebrands disease


A Type I Von Willebrands disease is characterized by very low levels of Von Willebrands factor B Type II Von Willebrands disease is characterized by a qualitative deficiency of Von Willebrabds factor

C Type II and Type III Von Willebrands disease are autosomal dominant disorders D Levels of Von Willebrands factor decrease in pregnancy

E Von Willebrands disease can be diagnosed from the clotting time


Explanation VON WILLEBRAND'S DISEASE ??? Inherited deficiency of von Willebrand factor (vWF).?? Type 1 - quantitative deficiency - autosomal dominant, mild bleeding disorder - improves during pregnancy?? Type 2 - qualitative deficiency - autosomal dominant, mild bleeding disorder - usually improves during pregnancy?? Type 3 - very low / absent vWF and low VIII - autosomal recessive, severe bleeding disorder - no improvement during pregnancy?? Diagnosed by reduced plasma ristocetin cofactor +/- reduced vWF? Pregnancy, exercise, stress, inflammation and recent surgery increase VIII and vWF levels IX levels do not rise significantly in pregnancy

Question 10 A 33 year old woman has been referred for colposcopy because of high grade dyskaryosis (moderate). Options for Questions 10-10

A Either an excision biopsy or a colposcopically directed punch biopsy should be undertaken B Biopsy is unnecessary if colposcopy is normal

C Biopsy is unnecessary if colposcopy shows CIN 1 D A punch biopsy should not be undertaken in such women

E A colposcopically directed punch biopsy should only be undertaken if local destructive therapy is being offered

(SAMPLE) 1- Early Pregnancy (SBA)

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