Fertility PDF

Obs & Gynae - Fertility & Gynaecology 1
Question: 1 of 64
Theme:Cardiac disease in pregnancy
A Atrial and ventricular ectopics
B Atrial flutter/fibrillation
C Long QT syndrome
D Palpitations
E Sinus tachycardia
F Supraventricular tachycardia
G Ventricular tachycardia
From the listed conditions please answer the following questions on cardiac disease in pregnancy:
The commonest arrhythmia associated in pregnancies with congenital heart disease.
Incorrect - The correct answer is Ventricular tachycardia
No treatment is required for this arrhythmia in pregnancy as it has no adverse effects.
Correct
This arrhythmia is typically associated with mitral valve disease.
Incorrect - The correct answer is Atrial flutter/fibrillation
The commonest arrhythmia in pregnancies with congenital heart disease is supraventricular tachycardia. It
can be treated with vagal manoeuvres. Adenosine can also be used and is safe in pregnancy and will reveal
any underlying flutter, Wolff-Parkinson-White syndrome or terminate the SVT.
Atrial and ventricular ectopics are common in pregnancy occurring in 50-60% of all pregnancies.
Reassurance can be given because they cause no adverse effects and no treatment is required. Patients
should be advised to avoid caffeine.
Atrial flutter and fibrillation are rare in pregnancy but are more commonly seen when there is mitral valve
disease. Treatment is with digoxin and this is safe in both pregnancy and breast feeding.
Thromboprophylaxis is required.
Question: 2 of 64
Theme:Chicken pox in pregnancy
A Chorioretinitis
B Disseminated intravascular coagulopathy
C Encephalitis
D Fever
E Idiopathic thrombocytopenic purpura
F Maculopapular rash
G
H
I
J
Meningitis
Pneumonitis
Shingles
Spontaneous first trimester miscarriage
For each of the following statements regarding chickenpox (varicella) in pregnancy, please choose the most
relevant feature / complication from the given list.
Please note each option may be chosen more than once.
Women who are taking systemic corticosteroids are at significantly increased risk of this complication.
Incorrect - The correct answer is Pneumonitis
Women who are viraemic during delivery are at increased risk of this particular complication.
Incorrect - The correct answer is Disseminated intravascular coagulopathy
The duration of this feature can be reduced following administration of aciclovir.
Incorrect - The correct answer is Fever
This feature is characteristic of fetal varicella syndrome.
Correct
This feature is indicative of neonatal varicella.
Incorrect - The correct answer is Maculopapular rash
The Royal College of Obstetricians and Gynaecologists (RCOG) clinical (green-top) guideline number 13
("Chickenpox in Pregnancy") contains a comprehensive review of the available evidence relating to
maternal, fetal and neonatal varicella infection and makes recommendations with respect to their
management.
It should be remembered that chickenpox in any adult is associated with a much higher incidence of
complications and death compared to chickenpox in childhood and therefore clinicians must be vigilant
when managing these cases.
The risk of potentially life-threatening pneumonitis [answer H] is increased amongst women who are
immunosuppressed (for example secondary to corticosteroid use [question 1] or HIV infection) and also in
women who have chronic lung disease and/or who smoke.
Women who are viraemic around the time of delivery [question 2] may develop disseminated intravascular
coagulopathy [answer B] or thrombocytopenia (albeit not idiopathic [answer E]) with an increased risk of
bleeding. They are also at increased risk of hepatitis.
Women who present within 24 hours of initial appearance of their rash and who are greater than 20 weeks
gestation should be offered aciclovir [question 3], which has been shown to reduce the duration of fever
[answer D] and symptomatology of maternal varicella infection.
Fetal varicella syndrome [question 4] is a rare complication of varicella infection prior to 28 weeks gestation
which results from subsequent in utero reactivation of the virus. It is characterised by eye defects (including
chorioretinitis [answer A], cataracts and microphthalmia), skin scarring, and limb hypoplasia and
neurological abnormalities (including microcephaly and cortical atrophy).
Neonatal varicella [question 5] generally results from vertical infection or direct skin to skin contact via the
mother, or occasionally from an affected sibling. It manifests as a classical maculopapular pruritic rash
[answer F] as in older children and adults.
Question: 3 of 64
Theme:The Natural History of Endometrial Carcinoma
A 5-6 years
B <5%
C 10-12 years
D 2-3 years
E 5 years
F 50-60 years
G 35-45 years
H <2%
I 10-20%
J 7 years
K 10 years
L 5-10%
M 2-3 months
For each scenario below, choose the single most likely time or time interval from the list of options.
Each option may be used once, more than once or not at all.
The peak age of presentation of endometrial carcinoma
Incorrect - The correct answer is 50-60 years
The times scale within which 80% of patients with recurrent disease will present following the treatment of
a Stage I tumour.
Incorrect - The correct answer is 2-3 years
Within this period, up to 80% of patients will be alive following radiotherapy for Stage I cancer of the
endometrium
Incorrect - The correct answer is 5 years

The percentage of women who commonly present with both cervical and endometrial carcinoma.
Incorrect - The correct answer is <2%
Peak incidence of endometrial cancer is the fifth decade of life.
Recurrent disease usually presents in the first two to three years.
Five year survival rate for stage one disease is 80%, stage II is 56% .
Less than 2% present with both cervical and endometrial tumours.
Question: 4 of 64
Are the following true or false concerning bacterial vaginosis?
Can be diagnosed by the finding of clue cells on microscopy
Incorrect answer selected
Cannot be detected by Gram staining
Causes a rise in the pH of vaginal secretions
Correct
Is often asymptomatic
Correct
Should be treated in pregnancy with clindamycin to help prevent late miscarriage and pre-term
birth
Correct
Gram staining of high vaginal swab is an appropriate way of detecting bacterial vaginosis (BV).
Clue cells alone cannot be used to diagnose BV, but they do form one of Amsel's criteria, three of which are
needed for the diagnosis of BV. The others include
Vaginal pH of 4.5 or above

The finding of a thin, white, homogenous vaginal discharge and
The production of fishy odour when 10% potassium hydroxide is added to the secretions.
Fifty percent of the women with BV are asymptomatic.

The treatment of choice in pregnancy for BV is clindamycin, which has been shown to reduce the risk of
pre-term delivery. Metronidazole is also an option.
Question: 5 of 64
A term infant is noted to have a cardiac murmur. The presence of the following would make it less likely to
be an innocent (flow) murmur:
Maternal diabetes
Correct
The murmur is diastolic
Correct
The mother has a history of small VSD
Correct
The mother was a smoker
The mother and baby have an accessory digit Incorrect answer selected
Features that would argue against this being a flow murmur would include the maternal history of CHD (3%
increased risk), maternal diabetes, and if the murmur is diastolic rather than systolic. An accessory digit is
quite common (autosomal dominant) and not associated with CHD. Maternal smoking is not associated with
CHD.
Question: 6 of 64
Theme:Drug treatment in pregnancy.
A Atenolol
B Calcium gluconate
C Diazemuls
D Ergometrine
E Intravenous gentamicin
F Intravenous penicillin V
G Magnesium sulphate
H Methyldopa
I Nifedipine
J Oxytocin
K Ritodrine
For each case below choose the single most appropriate drug treatment from the given list of options. Each
option may be used once more than once, or not at all.
A woman has a postpartum haemorrhage of 600 ml and the midwife notices that the uterus is atonic. She is
also suffering from pre-eclampsia and her blood pressure at present is 140/95 mmHg.
Incorrect - The correct answer is Oxytocin
This lady needs oxytocin rather than ergometrine. Oxytocin is preferable because the latter is associated
with marked arteriolar vasoconstriction and hence is contraindicated when the woman is hypertensive
because of the risk of a cerebrovascular accident.
A 25-year-old primigravid woman presents at 40 weeks' gestation with hypertension and proteinuria. She is
complaining of a severe frontal headache and has 2+ of ankle clonus.
Incorrect - The correct answer is Magnesium sulphate
This woman is at risk of eclampsia and therefore needs prophylactic anticonvulsants in the form of
magnesium sulphate. Although diazemuls has been used for these purposes, magnesium sulphate is the drug
of choice.
A 42-year-old woman has a booking blood pressure of 160/100 mmHg with no proteinuria. She is otherwise
fit and well and has been known to suffer from essential hypertension for which she has been treated with
beta-blockers in the past.
Incorrect - The correct answer is Methyldopa
Atenolol is contraindicated in pregnancy and in this case methyldopa would give the best control of
hypertension.
A 36-year-old woman presents at 29 weeks' gestation with a history of painful regular uterine contractions
for the last three hours. There is no evidence of ruptured membranes and the uterus is soft in between
contractions. There is some cervical effacement but no dilatation at present.
Incorrect - The correct answer is Nifedipine
This lady is at risk of preterm labour. Nifedipine is a smooth muscle relaxant by being a calcium channel
blocker and acts on the uterus. Ritodrine is generally avoided as the first line treatment, due to its
cardiovascular side-effects.
A woman is in active labour and is known to be a carrier of group B Streptococcus.
Incorrect - The correct answer is Intravenous penicillin V
Women who are carriers of group B Streptococcus need antibiotic cover in labour, and penicillin is the drug
of choice if they are not allergic to the drug.
Question: 7 of 64
In monochorionic twins with uncompensated placental arteriovenous shunts:
The donor twin may have olighydramnios.
Correct
The donor twin may have microcardia.
Correct
The recipient twin may have large glomeruli.
Correct
By definition the twins vary in Hb by > 5g/dl
The surviving twin is at risk of disseminated intravascular coagulation.
Correct
Correct
Placental vascular anastomoses occur with high frequency only in monochorionic twins. In monochorionic
placentas, the fetal vasculature is usually joined, sometimes in a very complex manner. The vascular
anastomoses in monochorionic placentas may be artery-to-artery, vein-to-vein, or artery-to-vein. They are
usually well enough balanced so that neither twin suffers. Artery-to-artery communications cross over
placental veins, and when anastomoses are present, blood can readily be stroked from one fetal vascular bed
to the other.
Vein-to-vein communications are similarly recognised and are less common. A combination of artery-toartery and vein-to-vein anastomoses is associated with acardiac fetus. This rare lethal anomaly (1:35,000) is
secondary to the TRAP sequence-Twin Reversed Arterial Profusion. Neodymium:YAG laser ablation of the
anastomoses, in utero, can treat heart failure of the surviving twin. In rare cases, one umbilical cord may
arise from the other after leaving the placenta. In such cases the twin attached to the secondary cord is
usually malnourished or dies in utero. Twins of widely discrepant size are usually monochorionic.
In the fetal transfusion syndrome, an artery from one twin delivers blood that is drained into the vein of the
other. The latter becomes plethoric and large while the former is anaemic and small. By definition, there is a
5 g/dl haemoglobin and 20% body weight difference in this syndrome. Maternal hydramnios in a twin
pregnancy suggests the fetal transfusion syndrome. Anticipating this possibility by preparing to transfuse the
donor twin or to bleed the recipient twin may be lifesaving. Death of the donor twin in utero may result in
generalised fibrin thrombin in the smaller arterioles of the recipient twin, possibly as the result of
transfusion of thromboplastin-rich blood from the macerating donor fetus. The surviving twin may develop
disseminated intravascular coagulation. Treatment of this highly lethal problem includes maternal digoxin,
selective twin termination, or Nd:YAG laser ablation of the anastomosis. Donor twin (arterial side):
Oligohydramnios Small premature, malnourished, hypoglycaemic Pale, anaemic, hypovolaemic Small
glomeruli Thin-walled arterioles Recipient twin (venous side): Polyhydramnios Large preterm, wellnourished Plethoric, polycythaemic, hypervolaemic, cardiac failure, Large glomeruli, Thick-walled
arterioles.
Copyright 2011 Dr Colin Melville
Question: 8 of 64
The following are true of infants with a single umbilical artery:
The incidence is 1:100.
Correct
Congenital anomalies are found in about 1/3 of cases.
Correct
There is an association with trisomy 18.
Correct
Associated defects may be subtle.
Correct
There is an association with Beckwith's syndrome.
A single umbilical artery is about 1%; the frequency is about 35-70/1,000 twin births. Approximately one
third of infants with a single umbilical artery have congenital abnormalities, usually more than one, and
many such infants are stillborn or die shortly after birth. 18-Trisomy is one of the more frequent
abnormalities. Since many abnormalities are not apparent on gross physical examination, it is important that
at every delivery the cut cord and the maternal and fetal surfaces of the placenta be inspected. The number
of arteries present should be recorded as an aid to the early suspicion and identification of abnormalities in
such infants.
Question: 9 of 64
Regarding retinopathy of prematurity:
All babies who have received oxygen should have their eyes examined until a corrected age of 44
weeks gestation.
It occurs in 50% of very low birth weight infants.
Cryosurgery or laser therapy may be indicated for grade 3 or 4 disease.
Correct
It is first detected at the equivalent of 32-38 weeks gestational age.
Correct
It may progress extremely rapidly.
Correct
Retinopathy of prematurity (ROP, retinalentral fibroplasia) affects vessels at the junction of the vascular and
non-vascularised retina. Follow-up only needs to take place until the retina is fully vascularised. Vascular
proliferation may progress to retinal detachment, fibrosis and blindness. It was previously the commonest
cause of blindness in children, but careful monitoring has reduced its incidence to a much smaller
proportion of very low birth weight infants (more in extremely preterm infants). This is usually only grade 1
or 2 ( reversible) rather than grade 3 or 4 (requiring treatment). It is first detected between 32 and 38 weeks
of age, but may progress rapidly. Severe visual impairment occurs in only 1% of low birth weight infants.
Question: 10 of 64
Respiratory distress syndrome:
Occurs in about 30% of premature babies of 34 weeks gestation.
Correct
Occurs more frequently in infants of diabetic mothers.
Correct
The lungs have low compliance.
Correct
Is commoner in girls.
Is more common in infants of mothers addicted to narcotics.
HMD occurs primarily in premature infants; incidence is inversely proportional to the gestational age and
birth weight. It occurs in 60-80% of infants less than 28 wk of gestational age, in 10-30% of those between
32 and 36 wk, in about 5% beyond 37 wk, and rarely at term. An increased frequency is associated with
infants of diabetic mothers, delivery before 37 wk gestation, multifetal pregnancies, caesarean section
delivery, precipitous delivery, asphyxia, cold stress, and a history of prior affected infants. The incidence is
highest among preterm male or white infants. Earlier lung maturation may occur when there is severe
premature separation of the placenta, premature rupture of the fetal membranes, narcotic addiction, or
maternal hypertensive and renal vascular disease. Alveolar atelectasis, hyaline membrane formation, and
interstitial oedema make the lungs less compliant, requiring greater pressure to expand the small alveoli and
airways.
Question: 11 of 64
Theme:Gynaecological Operations
A Abdominal hysterectomy
B Anterior repair
C Colposuspension
D Fenton's procedure
E Hysteroscopy
F Laparoscopy
G Myomectomy
H Posterior repair
I Sacrocolpopexy
J Vaginal hysterectomy
K Ventral suspension
For each case below choose the single most appropriate operation from the list of options:
A 26-year-old lady suffering from superficial dyspareunia following the birth of her last child 8 months ago
and the stitching of an episiotomy.
Incorrect - The correct answer is Fenton's procedure
A Fenton's procedure is excision of a fibrous band from the posterior fourchette of the vagina. It commonly
occurs after the mother has been stitched inappropriately at the time of delivery and scar tissue forms over
the posterior wall of the vagina which makes penetration at intercourse painful. The procedure simply recuts
the episiotomy and instead of suturing horizontally, sutures vertically re-ephithelialising with healthy
vaginal skin the excised band of fibrous tissue.
A 68-year-old lady in good health complaining of vaginal prolapse. Of note in her history she has had a
vaginal hysterectomy and repair five years previously.
Incorrect - The correct answer is Sacrocolpopexy
This case is for sacrocolpoplexy which is a complicated abdominal operation usually to treat recurrent
vaginal prolapse, the emphasis being on vaginal prolapse rather than the organs above it. In this the stitches
are placed in the vagina and stitched into the ligaments near the sacrum. It is a long operation and can be
associated with significant haemorrhage because of the involvement of the venous plexus, so people
undergoing this need to be in good health and have some symptomatic problems from the vaginal prolapse.
A 41-year-old lady with her family complete, with a diagnosis of moderate endometriosis.
Correct
The surgical treatment of choice for endometriosis is hysterectomy which will remove a lot of the infective
tissue and prevent any further endometrium being shed into the pelvic cavity. However, as it often occurs in
young women they are not willing to undertake it, as they wish to have children in the future. In this case,
however, her family is complete and rather than go along with a series of medical therapies which are not
without their complications, it would be reasonable to offer someone in this position a hysterectomy.
A 48-year-old lady complaining of leakage of urine on raised abdominal pressure such as coughing and
laughing.
Incorrect - The correct answer is Colposuspension
Colposuspension, which goes by many names, is an operation which hitches up the bladder and is the
treatment for genuine stress incontinence. However, it is important to exclude problems with detrusor
instability which may be characterised with symptoms such as frequency and nocturia before this operation
is performed. In most cases urodynamics are performed before colposuspension is considered.
In spite of other surgeon's jokes about the limited range of gynaecological procedures, there are in fact a
number of them, but their indication needs to be specific and picking the wrong operation can often lead to a
great deal of misery for the patient. In these particular cases we try to highlight some of the less common
procedures.
Question: 12 of 64
Theme:Endometriosis, treatment
A Bilateral oophorectomy
B Combined oral contraceptive pill
C Danazol
D GnRH analogue prior to operative procedure
E Mefenamic acid
F Oestrogen only
G Operative laparoscopy
H Progestogen only pill
For each case below, choose the single most appropriate treatment from the given list of options.
Each option may be used once, more than once, or not at all.
A 22-year-old with bilateral ovarian endometriomata and severe dysmenorrhoea.
Incorrect - The correct answer is GnRH analogue prior to operative procedure
A 32-year-old, incapacitated by intermittently severe abdominal pains due to adhesions.
Incorrect - The correct answer is Operative laparoscopy
A 19-year-old with dyspareunia and mild disease noted at diagnostic laparoscopy.
Incorrect - The correct answer is Combined oral contraceptive pill
A 42-year-old woman with severe endometriosis, wheelchair bound due to pulmonary fibrosis.
Incorrect - The correct answer is Danazol

A 39-year-old woman having undergone a total abdominal hysterectomy three years earlier, now suffering
from severe deep dyspareunia and premenstrual syndrome not improved by medical treatment.
Correct
Endometriomata require operative management if symptomatic; a pre-operative course of GnRH analogue is
thought to increase ease of operation.
Ovarian tissue is usually salvageable although oophorectomy may be necessary in the severest cases.
Pelvic and abdominal adhesions secondary to endometriosis are often successfully managed by laparoscopic
division of adhesions; medical management is not helpful.
The combined oral contaceptive pill (COCP) is useful in reducing the symptoms of dysmenorrhoea and
dyspareunia in younger women with mild disease who require contraception.
In those not fit for surgical procedures, danazol and GnRH analogues are the most effective treaments.
Severe dyspareunia and premenstrual symptoms in a woman whose fertility is not an issue may be treated
by oophorectomy if all else has failed.
Question: 13 of 64
Theme:Dyspareunia
A Atrophic vaginitis
B Carcinoma of the cervix
C Chronic PID
D Endometriosis
E Genital tract infection
F Post-operative scarring
G Retroverted uterus
H Vaginismus
For each case below choose the single most likely diagnosis from the list of options.
A 54-year-old married lady with no previous history of sexual dysfunction who complains of pain
throughout intercourse.
Correct
The lady clearly suffers from atrophic vaginitis. The age group would make her menopausal and that she
would have pain at penetration and during intercourse owing to failure of lubrication. Treatment is simple:
HRT and/or a simple water based lubricant.
A 17-year-old girl who has recently become sexually active, who also complains of needle phobia and
anorexia, and of pain at initiation of intercourse.
Incorrect - The correct answer is Vaginismus

Although vaginismus used to be common it is disappearing in our society and is often associated with
societies where sexual intercourse or premarital sex is a strong religious or social taboo. However, it is also
associated with neurotic compulsive disorders, particularly penetration phobias such as needle phobia, and
may be associated with anorexia.
As a sub-text it may also be a response to previous childhood abuse, and careful counselling and the
appropriate referral is often recommended.
A 31-year-old nulliparous lady who complains of progressive pain during intercourse which may continue
for some time afterwards, occurring at each intercourse and worsening over time.
Incorrect - The correct answer is Endometriosis
Endometriosis is the most likely, but not only diagnosis.
The woman is in the right age group and the clue is the nulliparity. The dyspareunia is normally deep, that
is, inside during penetration and is usually not position dependent. It inclines to get worse over time as the
disease progresses.
Dyspareunia can be a difficult subject clinically, and one that people may have limited experience with;
however, there are a number of important conditions that you need to be aware of, which have been
highlighted in the cases above.
Question: 14 of 64
Theme:Ovarian Neoplasia
A Arrhenoblastoma
B Cystic teratoma
C Clear cell tumour
D Endometrioma
E Granulosa cell tumour
F Fibroma
G Krukenberg tumour
H Serous mucinousadenoma
I Serous cystadenoma
For each case of suspected ovarian neoplasia shown, choose the single most likely pathological lesion from
the list of options:
Anterior cystic lesion noted on ultrasound and x ray to contain bony spicules found in a 21-year-old female.
Incorrect - The correct answer is Cystic teratoma
Cystic teratoma otherwise known as a benign tumour. This accounts for 12-15% of ovarian neoplasia and
the give away is that they contain numerous tissue like hair, teeth and bone and they are particularly
common in young women. They are the only kind of ovarian neoplasia that you are not protected against
from oral contraceptive pill usage.
A 45-year-old lady complaining of breathlessness and who was noted to have pleural effusions and bilateral
ovarian masses.
Incorrect - The correct answer is Fibroma
The syndrome described is Meig's syndrome and this is commonly associated with ovarian fibromas be they
benign or malignant. In this case benign pathology is probably sequestration of fluid to the ovary secondary
to hypoproteinaemia in general leading to third spacing, other ascites and/or pleural effusions but the
syndrome refers particularly to pleural effusions and ovarian masses.
A 75-year-old Japanese lady noted to have haematemesis and also bilateral ovarian swellings.
Incorrect - The correct answer is Krukenberg tumour
Krukenberg tumour refers to secondary tumour in the ovary from a gastro-intestinal primary particularly
stomach. The haematomas in the Japanese woman were meant to give a clue to the primary source and the
fact that this was most likely to be the primary source and the ovarian swellings were likely to be secondary.
There are numerous histological sub-classifications of ovarian tumours which can be complicated to learn.
Essentially they go along the axis of benign or malignant then versus the histological cell type. The
commonest group is of epithelial cell origin but there are also sex core tumours and embryonic tumours.
Again these need to be learnt as they make good material for questions.
Question: 15 of 64
Regarding the development of the skull sutures:
Craniosynostosis is due to dysfunctioning osteoblasts
The skull vault develops from mesenchyme

Correct
Scaphocephaly develops from premature fusion of the coronal suture
Occipital plagiocephaly is usually due to infant positioning
Correct
Scaphocephaly develops from premature fusion of the lamdoid suture
Craniosynostosis is defined as premature closure of the sutures, and may be primary or secondary to failure
of brain growth. The majority are idiopathic, with genetic syndromes accounting for 10%. The skull bones
develop from mesenchyme, and craniosynostosis may be due to abnormal skull base development disrupting
suture development. Osteoblasts and osteoclasts are not thought to be abnormal. Most cases are evident
from birth, and a prominent bony ridge from the affected suture (S) may be found, confirmed by skull x
rays. Specific forms include:
Scaphocephaly - sagittal suture.

Frontal plagiocephaly - coronal/sphenofrontal suture.
Occipital plagiocephaly - infant positioning.
Trigonocephaly - metopic suture.

Turricephaly - coronal/sphenofrontal sutures.
Single suture involvement is rarely associated with neurological problems. Surgery is only needed for
cosmetic appearance. Genetic disorders involving multiple sutures include:
Crouzon syndrome
Apert syndrome
Carpenter syndrome
Chotzen syndrome
Pfeiffer syndrome.
Question: 16 of 64
The following are useful in assessing the gestational age of an infant:
Posture
Correct
Elbow angle
Square window test
Correct
Nipple formation
Correct
Palmar creases
Compared with the premature infant of appropriate weight, the infant with retarded intrauterine growth has a
reduced birth weight and may appear to have a disproportionately larger head relative to body size; infants
in both groups lack subcutaneous fat. In general, neurologic maturity (e.g., nerve conduction velocity)
correlates with gestational age despite reduced fetal weight. Physical signs may be useful in estimating
gestational age at birth. Commonly used, the Dubowitz scoring system is accurate to 2 wk. An infant should
be presumed to be at high risk of mortality or morbidity if a discrepancy exists between the estimation of
gestational age by physical examination, the mother's estimated date of last menstrual period, and fetal
ultrasonic evaluation.
Dubowitz scoring consists of:
NEUROLOGICAL: Posture, square window, ankle dorsiflexion, arm and leg recoil, popliteal angle,
heel-to-ear, scarf sign, head lag, ventral suspension.
CUTANEOUS: Oedema, skin texture, colour, and opacity; lanugo; plantar creases; nipple, breast,
and genitalia formation; ear formation and firmness.
Question: 17 of 64
Theme:Vaginal Discharge
A Atrophic vaginitis
B Bacterial vaginosis
C Candidiasis
D Chlamydial cervicitis
E Foreign body
F Gonorrhea
G Non-specific vaginitis
H Syphilis
I Trichomoniasis
For each patient with vaginal discharge, select the most likely diagnosis:
A 25-year-old para 1+0 presented with vaginal discharge, soreness and dyspareunia since she met her new
boyfriend. Speculum examination revealed greenish white, frothy discharge on background hyperaemia of
the vagina and cervix "strawberry vagina". PH of the discharge was 5 and Gram staining showed polymorph
leukocytic infiltration with no growth after 24 hours of culture of the vaginal, endocervical and urethral
swabs.
Incorrect - The correct answer is Trichomoniasis
Symptoms arising when a new partner arrives on the scene raises suspicions of a STD. Trichomonas
vaginalis typically gives rise to a frothy offensive discharge usually greenish in colouration. The so-called
"strawberry" cervix with multiple petechial haemorrhages is often seen. The diagnosis is most easily proved
by identification of the protozoa in a wet film.
A 32-year-old obese para 3+1, known insulin dependent woman with diabetes presented to her GP
complaining of recurrent vaginal discharge with vulvo-vaginal soreness and dyspareunia. Speculum
examination revealed thick curdy white discharge with generalised vulvo-vaginal erythema. Bimanual
examination was unremarkable except for marked discomfort. PH of the vagina was 4.0 and Gram staining
revealed pseudomycelia spores and normal vaginal bacterial flora. The vaginal swab grew normal vaginal
flora.
Incorrect - The correct answer is Candidiasis
Candidiasis is usually more common in diabetics and is an opportunistic pathogen. Hence disturbance of
commensal vaginal flora with antibiotics is frequently a precursor to candidiasis, as may be any disturbance
in local or systemic immunity. There may be vulval itching and soreness with development of a pronounced
vulvovaginitis. The discharge is classically thick and curd-like.
A 21-year-old para 0+1 presented with history of lower abdominal pain and vaginal discharge for the last
week. She had the same problem two months ago when her GP treated her with antibiotics, which she used
for seven days. She also complained of vague right hypochondrial pain since then. Speculum examination
revealed yellowish discharge from the cervical canal. Bimanual examination revealed tenderness in the
pouch of Douglas with normal size uterus and no adnexal mass. PH of the discharge was 4.5 and Gram
staining showed mixed leukocytic infiltration with no growth on 24 hours culture of vaginal, endocervical
and urethral swabs. Her serum beta HCG was 2 IU/L with a normal period 10 days ago.
Incorrect - The correct answer is Chlamydial cervicitis
Chlamydia trachomatis is one of the commonest sexually transmitted pathogens. Patients may be
asymptomatic for months or years, although there may be an excessive vaginal discharge and lower pelvic
pain. It may also cause a perihepatitis (resulting in "Fitz-Hugh-Curtis" adhesions as seen at laparoscopy)
resulting in right hypochondrial pain. Current RCOG guidelines suggest antimicrobial treatment for
fourteen, not seven days which may be inadequate. Contact tracing and treatment of partners is also
essential.
Chlamydia is a Gram negative intracellular bacterium and can be demonstrated in cell culture although a
special transport medium is required. Detection of Chlamydia antigens is probably more reliable.
A 33-year-old P2+0 presented to her GP complaining of excessive vaginal discharge often staining her
undergarments. She felt quite embarrassed when her husband drew her attention to the malodour of the
discharge. Speculum examination revealed copious greyish-white "flour and water" discharge with "tiny
bubbles" and fishy smell on mixing it with 10% KOH. Bimanual examination was unremarkable. PH of the
discharge was 5.5 and Gram staining revealed deficiency of lactobacilli and a few vaginal cells with their
borders obscured by numerous tiny bacteria. Unfortunately, the GP forgot to take swabs for culture and
sensitivity.
Incorrect - The correct answer is Bacterial vaginosis
Bacterial vaginosis is one of the commonest causes of abnormal vaginal discharge. The usually dominant
lactobacilli are replaced by a mixture of different vaginal bacteria including Gardnerella vaginalis and
Bacteriodes species, as well as Streptococcus species, Mycoplasma hominis and Mobiluncus species. These
flora produce amines that give the characteristic fishy smell. Typically the pH is more than 4.5 and addition
of 10% KOH releases the volatile amines to the characteristic fishy smell. A wet film may show the so
called "clue cells" which are masses of small cells coating epithelial cells.
A 19-year-old girl was referred by her GP to the genito urinary medicine (GUM) clinic with history of
vaginal discharge since she came from holidays about four days ago. On questioning, she admitted to a
sexual encounter with a stranger abroad about one week ago. She was running 37.70C temperature and was
slightly tender in the lower abdomen.
Speculum examination revealed yellowish discharge from the cervical os with bilateral adnexal tenderness
and milking of urethra revealed same yellowish discharge from the urethra. There were no palpable masses
in the fornices. Appropriate swabs were taken for culture and Gram staining. The Gram staining result
reported Gram negative, oxidase positive, intra-cellular diplococci while the culture report was still awaited.
Incorrect - The correct answer is Gonorrhea
Women infected with Neisseria gonorrhoeae may have no symptoms. However, patients may complain of
excessive vaginal discharge and dysuria. On examination there may be a mucopurulent cervical discharge,
pyrexia and abdominal/pelvic tenderness. Ascending infection can cause pelvic inflammatory disease (PID)
and gonococcal perihepatitis. The organism typically infects columnar epithelium present in the endocervix,
urethra, rectum and pharynx. It is a gram negative intracellular diplococcus.
Question: 18 of 64
Theme:Treatment of menorrhagia
A Combined oral contraceptive pill (COCP)
B Depot progestagen injection
C GnRH analogues
D Dilatation and curettage
E Mefenamic acid
F Mirena coil
G Prostaglandin analogues
H Total abdominal hysterectomy (TAH)
I Tranexamic acid
J Trans-cervical resection of the endometrium
For each case of menorrhagia below, choose the single most appropriate treatment from the list of options.
A 32-year-old woman presents with heavy, prolonged but painless periods. She has had problems with
breast pains with previous use of the oral contraceptive pill. There is no obvious pelvic pathology on
transvaginal ultrasound.
Incorrect - The correct answer is Tranexamic acid
Tranexamic acid is the best choice in view of the painless menorrhagia.
A 43-year-old with frequent heavy periods causing anaemia and multiple pelvic adhesions requesting
definitive treatment.
Incorrect - The correct answer is Trans-cervical resection of the endometrium
The pelvic adhesions here would make hysterectomy a very difficult procedure. Hence TCRE may be the
most appropriate option here. Transcervical resection of the endometrium is the most commonly used
method of ablation for menorrhagia. The uterus is distended with glycine fluid at constant pressure to permit
resectoscopic visualisation of the target area.
A 19-year-old female presents with heavy, painful and irregular menstrual periods. She has had a number of
sexual partners.
Correct
The COCP may be the most appropriate choice in this scenario as the female is young and appears to need
contraception. The pill would be expected to regulate menses and reduce pain.
A 38-year-old multiparous female smoker presents with occasional heavy periods requiring contraception.
Incorrect - The correct answer is Mirena coil
The OCP would not be the most appropriate choice here due to the potential risks. However the Mirena coil
would be ideal in this scenario reducing and stopping periods in the majority and offering adequate
contraception.
A 22-year-old female presents with a one year history of painful and heavy periods. She has a history of
chronic active hepatitis and is also trying to conceive.
Incorrect - The correct answer is Mefenamic acid
Mefenamic acid would the most appropriate treatment as it reduces pain and bleeding. Tranexamic acid
would only be expected to reduce blood loss rather than alleviate pain.
Dilatation and curettage is not a treatment for menorrhagia.
Tranexamic acid is more effective than non-steroidal anti-inflammatory agents (NSAIDs) and progestagens
in treating menorrhagia, but unlike NSAIDs such as mefenamic acid does not reduce pain.
Transcervical resection of the endometrium removes fertility but is useful as an alternative to hysterectomy
in those who are unsuitable or unwilling for it, providing the uterine cavity is not distorted or very enlarged.
In the case of the patient with multiple pelvic adhesions this may be a more appropriate choice than
hysterectomy.
The COCP should not be used in liver disease, but progestagens may be; neither in someone trying for a
pregnancy.
The Mirena coil is a good treatment for menorrhagia in a multiparous woman and of course is also
contraceptive.
Question: 20 of 64
Theme:Contraception choice
A Combined oral contraceptive pill (COCP)
B Depot progestogen injection
C Diaphragm
D Intrauterine contraceptive device (IUCD)
E Mirena coil
F Progesterone only pill
G Schering PC4
H Tubal occlusion
For each case below, choose the single most appropriate contraceptive choice from the given list of options.
An 18-year-old student four days after unprotected intercourse.

Incorrect - The correct answer is Intrauterine contraceptive device (IUCD)
An IUCD may be fitted up to five days after unprotected intercourse; Schering PC4 (post coital
contraceptive pills) may be used up to 72 hours afterwards.
A breast feeding mother of four children, three weeks post partum who wishes to become pregnant again
within one year.
Incorrect - The correct answer is Progesterone only pill
The COCP should not be used while breastfeeding. Depot progestogens may be associated with a delay in
return of normal menstruation and ovulation once discontinued.
A 37-year-old multipara with menorrhagia who smokes 20 cigarettes a day.
Incorrect - The correct answer is Mirena coil
The COCP should not be used in smokers over the age of 35.
A 30-year-old with heavy periods and a steady relationship.
Correct
Pelvic infection is a contraindication to IUCD use. The COCP and Mirena coil both reduce menstrual blood
loss.
A 19-year-old with two children, recent pelvic infection and history of deep vein thrombosis who finds it
difficult to remember her medications.
Incorrect - The correct answer is Depot progestogen injection
Further reading:
Post partum contraception
Question: 21 of 64
Theme:Management of Polycystic Ovary Syndrome
A Appetite suppressant
B Bilateral oophorectomy
C Clomiphine citrate
D Combined formulation of oestrogen with cyproterone acetate
E GnRH agonist
F Metformin and clomiphene
G No treatment
H Ovarian diathermy
I Weight loss
For each patient below select the single most appropriate management from the given list of options.
A 26-year-old woman presents with oligomenorrhoea with approximately six periods per year. On
examination, she has a body-mass index of 36 kg/m2. Investigations confirm a diagnosis of polycystic ovary
syndrome (PCOS).
Incorrect - The correct answer is Weight loss
Weight loss is the most appropriate primary modality of treatment for this patient as it would be expected to
be as effective as any pharmacological intervention if successful.
A 23-year-old female is concerned regarding deteriorating hirsutism and oligomenorrhoea. She does not
wish to conceive and currently has no sexual relationship. On examination she has a BMI of 27 and early
visible change of hirsutism.
Incorrect - The correct answer is Combined formulation of oestrogen with cyproterone acetate
The best approach is probably Dianette providing there are no contraindications as this offers good
treatment of hirsutes plus regulation of cycles.
A 32-year-old woman with a BMI of 34.5kg/m2 with a history of oligomenorrhoea is seeking fertility. She
has tried to lose weight unsuccessfully and finds difficulty with diet. Her investigations confirm PCOS.
Incorrect - The correct answer is Metformin and clomiphene
Metformin and clomiphene would be the preferred choice here rather than metformin alone based on studies
published in the NEJM indicating significantly higher fertility rate with the two combined.
A 25-year-old female with a diagnosis of PCOS presents with heavy, irregular periods. She has no partner at
present and does not wish to conceive. On examination she has a BMI of 29 kg/m2 and some slight
hirsutism.
Incorrect - The correct answer is Combined formulation of oestrogen with cyproterone acetate
The combined OCP Dianette would again be a useful choice in treating the menorrhagia/oligomenorrhoea
and may improve the hirsutism.
A 22-year-old female undergoes a pelvic ultrasound scan for occasional dysmenorrhoea. The report notes
multiple small follicles seen in the periphery of both ovaries compatible with a diagnosis of polycystic
ovaries. She has a BMI of 23.2 kg/m2 has regular periods and no features of hirsutism.
Incorrect - The correct answer is No treatment
This is a co-incidentally noted appearance of PCO but the patient is asymptomatic. There is no treatment
required. Appearances compatible with PCO may be seen in up to 20% of scans.
Clomiphene is particularly useful in stimulating ovulation in women with polycystic ovary syndrome
(PCO), but these women are also particularly prone to ovarian hyperstimulation syndrome (OHSS).
Recently metformin has also been found to be very successful in stimulating ovulation, particularly when
combined with clomiphene in the obese PCOs.
The most effective initial treatment in an overweight/obese woman with PCO and amenorrhoea is for her to
lose weight; a dietician is often useful. Appetite suppressants are either used with extreme caution or not at
all and are not recommended in this scenario.
The combined oestrogen/cyproterone formulation contraceptive pill is useful as a contraceptive, regaining
cycle control and reducing hirsutism. If hirsutism is the major problem, cyproterone may be used on its own
in larger dosages but will take many months to work.
The diagnosis of polycystic ovarian disease cannot be made simply on the classical ultrasound findings;
there must also be secondary amenorrhoea.
Gonadotropin-releasing hormone (GnRH) agonists and bilateral oophorectomy have no place in the normal
management of PCO .
Question: 22 of 64
Theme:Presentation of gynaecological disease in a 24-year-old woman
A Adenomyosis
B Cervical intraepithelial neoplasia (CIN)
C Chronic pelvic inflammatory disease (PID)
D Ectopic pregnancy
E Endometriosis
F Fibroids
G Polycystic ovarian disease (PCO)
H Torsion of ovarian cyst
For each 24-year-old woman, who is otherwise well, choose the single most likely diagnosis from the given
list of options.
Intermittent severe unilateral pelvic pain accompanied by nausea and vomiting over a two day period with
no history of fever.
Incorrect - The correct answer is Torsion of ovarian cyst
Deep dyspareunia and dysmenorrhoea; not sexually active until two months ago.
Incorrect - The correct answer is Endometriosis
Heavy menorrhagia and a palpable central mass arising from the pelvis.
Incorrect - The correct answer is Fibroids

Not using contraception, previous tubal surgery and unilateral pelvic pain.
Incorrect - The correct answer is Ectopic pregnancy
Dysmenorrhoea, irregular periods and recurrent episodes of green/yellow vaginal discharge.
Incorrect - The correct answer is Chronic pelvic inflammatory disease (PID)
Torsion of an ovarian cyst classically causes acute, sharp, unilateral abdomio-pelvic pain associated with
nausea and vomiting.
Chronic PID usually follows several episodes of acute, partially treated PID and would be highly unlikely in
someone with very limited sexual exposure to infection.
Adenomyosis is very unlikely in someone in her 20s and CIN is asymptomatic.
Previous tubal surgery and unilateral pelvic pain, especially in the presence of more than four weeks
amenorrhoea and/or vaginal bleeding raises concern over ectopic pregnancy.
PID is more usually associated with bilateral pelvic pain.
Gynaecological conditions and diseases...
Question: 23 of 64
Theme:Contraception
A Combined oral contraceptive pill
B Condom
C Copper intrauterine device
D Depot progesterone injection
E Diaphragm
F Mirena intrauterine device
G Progesterone only pill
H Rhythm method
I Sterilisation
J Vimule
For each of the following, select the most appropriate method of contraception:
A 27-year-old woman with poorly controlled inflammatory bowel disease (IBD) is keen for reliable
contraception. Her periods are heavy but regular. She does not have a regular partner.
Incorrect - The correct answer is Condom
IBD means that gut absorption may be impaired. Condom contraception may be the best option here given
the lack of a regular partner.
A 40-year-old woman smoker who has rheumatoid arthritis affecting her hand joints requests contraception.
She has a history of pelvic infections and is not keen on operations.
Incorrect - The correct answer is Depot progesterone injection
The history of pelvic infection precludes the use of intrauterine contraception. The patient is over 35 and a
smoker, therefore progesterone-only contraception is favoured, due to its lower cardiovascular risk.
Rheumatoid disease may affect hand function and depot contraception will not be affected by enzymeinducing drugs which may be used for the treatment of the rheumatoid.
A 22-year-old student has a history of pelvic inflammatory disease (PID). She has already had two
terminations of pregnancy and she forgets to take the pill. She does not have a regular partner.
Incorrect - The correct answer is Depot progesterone injection
This patient is not reliable enough for OCP. A coil is contraindicated given the history of PID. The barrier
method is not an option, and sterilisation is most definitely not indicated in a patient of this age. A depot
injection is the best option.
A 19-year-old student has a history of asthma and iron deficiency anaemia. She has recently become
sexually active. Her grandmother is hypertensive and her mother has recently had a malignant melanoma
excised from her leg. She is normotensive and a non-smoker.
Correct
The risk factors listed here are not contraindications to the combined OCP. The combined OCP is effective
contraception in an individual who reliably takes the medication.
Different methods of contraception...
Question: 24 of 64
Is secondary amenorrhoea associated with the following?
Anorexia nervosa
Correct
Cone biopsy
Correct
Polycystic ovary syndrome (PCOS)
Correct
Sheehan's syndrome
Turner's syndrome
Correct
Common causes of amenorrhoea (commonest being pregnancy) include
Weight loss
Excessive exercise
PCOS
Depression.
Turner's syndrome is a cause of primary amenorrhoea not secondary.

Sheehan's syndrome is as a consequence of obstetric pituitary infarction with secondary amenorrhoea due
to hypogonadotrophic hypogonadism associated with the hypopituitarism.
Cervical stenosis may occur after cone biopsy. There is usually a history of cyclical pre-menstrual
symptoms and dysmenorrhoea and haematometra can usually be seen on scan. Technically this is more
precisely termed cryptomenorrhoea.
Question: 25 of 64
Theme:Causes of amenorrhoea
A Anorexia nervosa
B Congenital adrenal hyperplasia
C Drug induced
D Menopause
E Ovarian tumour
F Polycystic ovarian syndrome (PCOs)
G Pregnancy
H Primary ovarian failure
I Prolactinoma
J Turners syndrome
Select the most likely diagnosis from the given list for the following patients who present with
amenorrhoea:
Normal ranges: Oestradiol 130-800, Prolactin 50-450, LH 2-20, FSH 2-20, Testosterone less than 3.
A 21-year-old female presents with a six month history of amenorrhoea and fatigue. On examination her
oestradiol is less than 80 nmol/l, her LH is 35 mu/l, FSH 42 mu/l, prolactin 298 mu/l and testosterone 1
nmol/l.
Incorrect - The correct answer is Primary ovarian failure
An 18-year-old female presents with a four month history of amenorrhoea, weight gain and hirsutism.
Results reveal an oestradiol of 550 nmol/l, LH 8.8, FSH 3.2, prolactin 500 mu/l and testosterone 3.1 nmol/l.
Incorrect - The correct answer is Polycystic ovarian syndrome (PCOs)
The low oestradiol with elevated luteinising hormone (LH) and follicle-stimulating hormone (FSH)
indicates primary ovarian failure.
As this is secondary amenorrhoea and with no other mention of features of Turner's syndrome the most
probable diagnosis is an autoimmune primary ovarian failure. Ovarian auto antibodies may be detectable.
This is not the menopause which is a physiological ovarian failure occurring with a mean age of
approximately 50.
The typical features of PCOs include
Normal to high oestradiol concentrations (amenorrhoea is not due to a low oestradiol in this
condition)
Slightly elevated androgens and often
A modest elevation of the prolactin (hyperprolactinaemic varian of PCOs is quite common).
Similarly, the elevated LH to FSH ratio (greater than 2:1) is suggestive.

Again a point to note is that if the amenorrhoea were due to hypeprolactinaemia, the oestradiol would be
suppressed.
Question: 26 of 64
Question: 5 of 44
Time taken: 02:21
Theme:Cervical screening
A No further screening required
B Refer for colposcopy
C Repeat smear within 1 month
D Repeat smear in 6 months
E Screen again in 12 months
F Screen again in 2 years
G Screen again in 3 years
H Screen again in 5 years
Select the most appropriate option for the following cases:
At time of screening a 26-year-old female taking the oral contraceptive is noted to have ectropion which is
confirmed on smear.
Incorrect - The correct answer is Screen again in 3 years
Ectropion is common and is associated with pregnancy and the oral contracpetive. In this young woman,
cervical screening should be performed again in three years which is the recommendation for normal smears
in women below 50 years of age.
A 27-year-old female had a cervical smear that is reported as mild dyskaryosis.
Incorrect - The correct answer is Repeat smear in 6 months
The suggested guidance of this abnormal smear reflecting cervical intraepithelial neoplasia (CIN) 1 is a
repeat smear in six months time. If at that stage the smear again shows dyskaryosis then colposcopy is
required. If the smear reverts back to normal then the smear should be repeated in six months again.
A 35-year-old female is noted to have an abnormal smear which is reported as moderate dyskaryosis - CIN
II.
Incorrect - The correct answer is Refer for colposcopy
The recommendations sugest that patients with CIN II or III require colposcopy and treatment.
Question: 27 of 64
Theme:Level of Risk
A 1 in 1
B 1 in 2
C 1 in 4
D 1 in 20
E 1 in 100
F 1 in 500
G 1 in 1000
H 1 in 2000
I 1 in 10000
Select the most appropriate level of risk that applies in the following scenarios:
A couple in their early twenties enquire as to the risk of Down syndrome in their pregnancy.
Incorrect - The correct answer is 1 in 2000
The risk of Down syndrome increases with maternal age but the risk is approximately 1 in 1500 - 2000 in
this age group.
A 30-year-old female has been trying to conceive for quite some time and is now eight weeks pregnant. She
is fearful concerning miscarriage and enquires as to the risk of spontaneous abortion.
Spontaneous abortion after the eight week of pregnancy is not uncommon and cccurs in up to 8%. Risk
increases with increasing maternal and paternal age.
A woman who is 12 weeks pregnant is having amniocentesis and wishes to know the risk of miscarriage
following this procedure.
The risk of miscarriage following amniocentesis or chorionic villous sampling is estimated at between 0.5 1%.
Question: 28 of 64
Are the following statements true or false regarding third degree uterine prolapse?
Can cause difficulty in defaecation
Correct
Can manifest as overflow incontinence
Correct
Is always painful
Is associated with cervical ulceration
Correct
Risk is increased in multiparous patients
Correct
Third degree uterine prolapse is uterine descent with cervical protrusion beyond the introitus.
They are usually painless, unless ulcerated, and can cause difficulty in defecation by pressure on the anterior
wall of the rectum.
Vaginal examination should be considered in elderly patients with constipation or urinary incontinence or
retention in order to rule out uterine prolapse.
Question: 29 of 64
A mobile retroverted uterus:
Can become incarcerated in the pelvis at 14 weeks of pregnancy
Can cause constipation
May be a cause of dyspareunia
Correct
May be associated with dysmenorrhoea
May be associated with subfertility
Fifteen percent of females have retroverted uterus and it is rarely a cause of backache.
Retroverted uterus is associated with dyspareunia, but is not a recognised cause of constipation, subfertility
nor dysmenorrhoea. However, a fixed retroverted uterus may be a feature of endometriosis.
We do not know of any evidence to support the suggestion of incarceration in the pelvis at 14 weeks.
Question: 30 of 64
Is it true that primary dysmenorrhoea is the following?
Always pathological
Caused by endometriosis
Effectively treated with prostaglandin synthetase inhibitors
Correct
Pain during the first few cycles following menarche
Pain starting 2-3 days before menstruation
Primary dysmenorrhoea is defined as pain on first day of menstruation but improves as menstruation
proceeds. It is usually benign.
Secondary dysmenorrhoea is pain one to five days before the onset of menstruation, and is relieved on
menstruation. It is usually associated with pathology.
Mefanamic acid is a prostaglandin synthetase inhibitor which may be effective pain relief in primary
dysmenorrhoea.
Secondary dysmenorrhoea is classical of older women with endometriosis.
Question: 31 of 64
A 30-year-old female is undergoing assisted reproduction and develops lower abdominal discomfort
associated with nausea. A diagnosis of ovarian hyperstimulation syndrome (OHSS) is suggested.
Which of the following symptoms would suggest that this patient should be hospitalised?
A blood pressure of 106/78 mmHg
A pulse of 100 bpm
A respiratory rate of 32/min
Correct
Dyspnoea
Correct
Tense abdomen
Correct
Features that would merit hospitalisation in OHSS include
Tachypnoea
Hypotension (orthostatic is typical)
Tense ascites/abdomen
Oliguria
Electrolyte imbalance
Intractable vomiting, etc.
Question: 32 of 64
Do the following features define severe ovarian hyperstimulation syndrome (OHSS)?
Blood pressure of 118/78 mmHg
Chest x ray revealing a small left pleural effusion

Ovarian diameter of 4.5 cm
Plasma sodium concentration of 125 mmol/l
Urea concentration of 12.1 mmol/l
It is important to ascribe a severity to cases of OHSS for audit purposes, and a classification of mild,
moderate, severe or critical exists.
Evidence of ascites on ultrasound, which is not detectable clinically, defines a case as moderate, as does
ovarian size of 10 cm.
Nausea and vomiting are features of moderate OHSS; however, thrombotic complications and adult
respiratory distress syndrome (respiratory failure resistant to oxygen therapy) would define the case as
severe.
Further reading:
RCOG Green-top Guideline #5
Question: 33 of 64
Which of the following women are at increased risk of developing ovarian hyperstimulation syndrome
(OHSS) during assisted reproduction?
Obese women
Women over the age of 30
Women treated with a GnRH agonist
Correct
Women who have previously undergone assisted reproduction
Women with polycystic ovarian syndrome
Correct
Increased risk of OHSS is found in association with
A younger age group

Lower BMI (not the obese)
Polycystic ovary syndrome (PCOS)
Gonadotropin-releasing hormone (GnRH) agonists
Human chorionic gonadotropin (HCG) for luteal support
High oestrogen concentrations
Increased number of follicles during treatment.
Further reading:
RCOG Green top Guideline #5
Question: 34 of 64
Are the following true regarding hirsutism?
Is a side effect of cyproterone acetate therapy
Is a side effect of danazol therapy
Correct
Is associated with Cushing's syndrome
Correct
Is associated with prolactinoma
Is associated with spironolactone therapy
Hirsutism may be associated with therapy such as phenytoin, danazol, steroids and other androgenic
compounds.
Spironolactone and cyproterone acetate have anti-androgenic properties and are used in the treatment of
hirsutism.
Question: 35 of 64
Are the following true regarding hirsutism?
Affects approximately 20% of the female population
DHEAS concentrations are typically elevated.

Elevated 17 hydroxyprogesterone (17OHP) concentrations are found in congenital adrenal
hyperplasia.
Correct
Is commonly due to PCOS.
Correct
Severity correlates directly with testosterone concentration
Concentrations of most hormones are typically normal in hirsutes and no clear correlation exists between
hirsutism and testosterone concentrations.
It affects roughly 8% of the female population and typically due to polycystic ovary syndrome (PCOS)
which is found in approximately 6% of the population.
Congenital adrenal hyperplasia (CAH) is associated with elevated 17OHP.
Question: 36 of 64
Post-operative pelvic deep vein thrombosis
Occurs more commonly in subjects with superficial leg varicosities.
Correct
Is associated with anaemia.
Has a greater risk of embolisation than femoral DVT.
Correct
Is accurately diagnosed with Doppler ultrasonography.
Aspirin is an effective prophylactic therapy.
Isolated pelvic DVT is associated with pregnancy and unlike femoral DVT is not adequately revealed by
ultrasonography and may be diagnosed with MR venography or traditional venography. Prophylactic low
molecular weight heparin is an effective prophylactic. Other predisposing factors include obstructions,
coagulation defects polycythaemia, thrombocythaemia, coagulopathies and sepsis.
Question: 37 of 64
Can Hegar's sign be elicited in the following?
At term
At 24 weeks gestation
In early pregnancy
Correct
In labour
Pseudocyesis
Hegar's sign is compressibility and softening of the cervical isthmus (the portion of the cervix between the
uterus and the vaginal portion of the cervix), a sign that may be present during the fourth to sixth weeks of
pregnancy.
Question: 38 of 64
Recognised complications of gynaecological laparoscopy include:
damage to the anterior division of the lumbosacral plexus
haemoperitoneum
Correct
puncture of common iliac blood vessels
Correct
puncture of the inferior epigastric artery
Correct
are 10 fold lower than complications seen at laparotomy Correct

The most catastrophic and feared complications are injury to major blood vessels-the iliac arteries, vena
cava and aorta. The incidence is 0.4/10,00 for bowel injuries and 0.2 /1000 for major vessel damage. Bowel
injuries occur in 8.4/1000 laparotomies.
Question: 39 of 64
Is the serum luteinising hormone (LH) concentration raised in the following?
Acromegaly
Anorexia nervosa
Cystadenocarcinoma of the ovary
Hirsutism
Correct
Premenstrual tension
Acromegaly is associated with elevated growth hormone concentrations and LH may be low due to
associated hypogonadotrophic hypogonadism.
LH is raised in cases of hirsutism associated with polycystic ovary syndrome (PCOS).

Levels are low in anorexia nervosa and in functional ovarian tumours as well as in carcinoma concentrations
may be lowered.
Question: 40 of 64
Do recognised causes of postmenopausal bleeding (PMB) include the following?
Atrophic vaginitis
Correct
Benign teratoma of the ovary
Hepatic cirrhosis
Correct
Phaeochromocytoma
Preinvasive carcinoma of the cervix
Atrophic changes to the genital tract are the most common cause of postmenopausal bleeding but must not
be assumed to be the cause until other pathology has been ruled out.
Oestrogen secreting tumours of the ovary can cause PMB as can cirrhosis with deranged coagulation and of
course other tumours of the gastrointestinal tract.
Teratomas of the ovary have a median age of presentation of 30 years and are usually non-hormonal.
Question: 41 of 64
Is it true that in women with polycystic ovarian syndrome (PCOs), metformin treatment has been shown to
cause the following?
Cause weight loss
Improve rates of rates of conception when used a single agent
Correct
Increase insulin secretion
Reduce androgen levels
Correct
Reduce hepatic glucose production
Correct
Metformin reduces insulin secretion but studies reveal that it is not effective as a agent for weight loss.
Studies show that metformin is effective in increasing conception either used alone or in conjunction with
clomiphene citrate in PCOs.
Again, through improvements in insulin sensitivity, androgen concentrations decline and there is reduced
hepatic gluconeogenesis.
Question: 42 of 64
Are the following true regarding ureteric injury following gynaecological surgery?
Bilateral injury is more common than unilateral injury
Birch colposuspension is rarely associated with ureteric injury

The incidence of ureteric injuries following a major gynaecological procedure is 2%

Correct
The ureters are unlikely to be injured during the ligation of the infundibulo-pelvic ligaments
Ureteric injuries are more common with abdominal procedures than vaginal procedures Correct
The anatomical proximity of female urinary and genital tract makes ureteric injury a constant threat during
gynaecologic surgery.
It is important to know the incidence of injury associated with procedures so that the patient can be
consented after being informed. Incidence is 0.4-2.5% for benign conditions but could be as high as 30% in
operations for malignancies.
Unilateral injury is more common with bilateral injury occurring in only 10% of cases.
In vaginal hysterectomy unless there is complete procedentia there is no distortion of anatomy of lower
urinary tract and therefore less injuries compared to abdominal procedures.
The ureter is very vulnerable to injury at the infundibulopelvic ligament.
Birch colposuspension is associated with ureteric injury.
Question: 43 of 64
Are the following true regarding chronic pelvic pain?
Approximately 70 % of women who present with chronic pelvic pain in whom no pathology is
found have a history of sexual abuse
Correct
Diagnostic laparoscopy is the gold standard for the diagnosis of chronic pelvic pain Incorrect
answer selected
Diverticular disease is a cause
Correct
The pain fibres of the uterus and adnexae share the same neurological tract as the ileum, transverse
and sigmoid colon and rectum
Correct
Transvaginal scanning and MRI are useful tests to diagnose adenomyosis
Correct
Diagnostic laparoscopy was considered as the gold standard in the diagnosis of chronic pelvic pain in the
past. But now it is better seen as a second line of investigation if other therapeutic interventions fail.
The pain signals from uterus, adnexae, ileum, colon and rectum travel through sympathetic nerves to the
spinal routes T10-L1.
The cervix descending colon and rectum also share common innervation through the parasympathetic
nerves through the pelvic plexus to enter the spinal cord between S2-S4.
Question: 44 of 64
Are the following true of urinary incontinence?
10% of patients with detrusor instability may never develop stable bladder function
Correct
Affects approximately 5% of women over the age of 65
Anterior colporrhaphy gives a very high success in treatment of GSI
Birch colposuspension gives a success of 80-90%

Correct
In women with symptoms suggesting GSI urodynamic test will demonstrate DI in 10-15% of cases
Correct
Urinary incontinence is common affecting 20-30% of women over the age of 65.
Risk factors include
Multips
Twin pregnancies
Obesity
Vaginal versus lower segment caesarian section (LSCS).
Anterior colporrhaphy treats anterior vaginal wall prolapse but is less likely to cure stress incontinence.
Question: 45 of 64
Are the following true of menorrhagia?
40% of patients with menorrhagia have adenomyosis
Correct
Endometrial ablation is more successful in the presence of fibroids
Normal menstrual blood loss is 100-150 ml
Occurs more commonly in anovulatory cycles
Pipelle sampling helps to diagnose adenomyosis
Only 10% of patients with menorrhagia have anovulatory cycles.

Polyps fibroids and adenomyosis are associated with lower success rates.
Normal menstrual blood loss is 60+/- 20 ml.
Diagnosis of adenomyosis can be made only after hysterectomy.
Question: 46 of 64
Are the following true regarding endometriosis?
65% of patients have ovarian involvement
Correct
Disease severity is an indicator of the amount of pain experienced by the patient
Fixed retroversion of the uterus is a variant of normality
Superficial dyspareunia is a common presentation
The incidence is highest in those investigated for chronic pelvic pain
Disease severity correlates very poorly with the pain experienced.

Mobile retroversion is a normal finding in about 20% of women.
Fixed retroversion is usually secondary to underlying disease.
Question: 47 of 64
In women with polycystic ovarian syndrome (PCOs), are the following statements true?
Acanthosis nigricans is a feature
Correct
Amenorrhoeic intervals of more than three months can lead to endometrial hyperplasia Correct
Endometrial biopsy is recommended if the endometrium is persistently thickened on transvaginal
ultrasound
Correct
Regular induction bleeds are not recommended in oligomenorrhic women
There is an increased risk of breast cancer
Regular induction bleeds are recommended in oligomenorrhic women, hence the reason why PCOs is
associated with an increased risk of endometrial neoplasia.
There is no clearly increased risk of breast cancer associated with PCOS.
Acanthosis nigricans, a browny, velvety pigmentation is found in the axillae and back of neck and is a
feature of underlying insulin resistance.
Question: 48 of 64
Are the following statements correct?
30% of women with congenital absence of vagina have renal tract abnormalities
A cervical smear should be taken in all sexually active adolescents
Correct
Ovarian growths are associated with precocious puberty in 10% of cases

Correct
The diagnosis of premature ovarian failure in a 20-year-old female can be made if the oestradiol
levels are below 100 pmol/l.
Treatment with depot progesterone is associated with irregular bleeding in 15% of users Correct
When investigating primary amenorrhoea in women with lower genital tract abnormalities imaging the renal
tract is also important as 30% have renal tract abnormalities.
It is not appropriate to do cervical smears in adolescents but may be necessary when investigating irregular
bleeding in sexually active adolescents.
Progesterone causes irregular or prolonged breakthrough bleeding in 15-20% of users.
Reduced oestradiol levels are not sufficient to confirm diagnosis of premature ovarian failure; raised
follicle-stimulating hormone (FSH) levels should be confirmed.
Question: 49 of 64
Are the following true regarding ovarian cyst?
Are likely to be malignant in less than 1 in 10 000 women of reproductive age
Are the commonest cause of hospital admissions in women
Correct
If malignant, are the commonest cause of death due to cancer in women Incorrect answer selected
In simple cysts, conservative management is followed by spontaneous resolution in approximately
50% of cases
Correct
Is malignant in less than 1% if uniloculate and smooth walled on ultrasound Correct
Ovarian cysts are the fourth most common cause of hospital admission and third most common cause of
cancer related deaths.
Treatment may be conservative in the form of repeated scans.
In 50% of cases there is spontaneous resolution.
Question: 50 of 64
Are the following true regarding ovarian cysts in postmenopausal women?
Are found in up to 20% of postemenopausal females
May need a transabdominal ultrasound for assessment if large in size
Correct
Should always be investigated initially at an oncology centre
Should always be investigated with a transvaginal ultrasound
Correct
Should always be investigated with CA125 and Doppler ultrasound
There is no absolute role as yet for Doppler ultrasound in the investigation of ovarian cysts.
The initial investigation does not require oncology referral.
Ovarian cysts occur in
30% of females with regular menses

50% of females with irregular menses and
6% of postmenopausal women.
Question: 50 of 64
Can intermenstrual bleeding be treated effectively with the following?
Cervical cautery
Combined oral contraceptive pill (OCP)
Correct
Cyclical progestogens
Correct
Mefenamic acid
Progesterone only pill
If the intermenstrual bleeding is caused by physiological events and is due to an excess fall in oestrogen
levels post ovulation, it is best mananged by OCP or cyclical progestogens, given from day 5-25 of the
cycle.
Question: 51 of 64
Which of the following do complications of diagnostic laparoscopy include?
Bowel perforation 0.04%
Correct
CO2 embolism.
Major vessel injury 0.02%
Correct
Shoulder tip pain
Correct
Wound site hernia
Correct
As state in the RCOG greentop guideline 'Preventing Laprascopic Injury 2008':

'The incidence of complications associated with laparoscopic procedures varies considerably
between reports, depending on the experience of the surgeons and the complexity of operations
undertaken; figures range between 1.0/1000 and 12.5/1000 for all complications.'
However, the guideline overall quotes the incidence of bowel injury as 0.4/1000 (0.04%) and of major
vessel injury as 0.2/1000 (0.02%).
Carbon dioxide embolism is not considered to be a complication of laprascopic surgery.
Wound site hernia is a known comparitively commom complication of larparscopic surger.
Shoulder tip pain is something not infrequently experience by patients following this surgery and in order to
reduce post-operative anxiety, they should be warned about this in advance.
For more information the RCOG guideline referred to above can found at the following link:
http://www.rcog.org.uk/files/rcog-corp/uploaded-files/GT49PreventingLaparoscopicInjury2008.pdf
Shoulder tip pain is a common complication of the laparoscopy.

Unsutured rectus sheath wound of less than 10 mm rarely leads to development of hernias.
Question: 52 of 64
May painful periods result from the following causes in adolescents?
Endometriosis
Correct
Imperforate hymen
Non-communicating uterine horn
Correct
Turner syndrome
von Willebrand disease
Endometriosis is becoming increasingly recognised as a cause of dysmenorrhoea in teenagers.

An imperforate hymen presents with cyclical pain, but the patient is amenorrhoeic due to obstruction.
A non-communicating uterine horn will cause increasing dysmenorrhoea but can be missed due to the
presence of normal menstruation from the unobstructed side.
Turner syndrome causes amenorrhoea.
von Willebrand disease can make the periods heavier but does not cause dysmenorrhoea.
Question: 53 of 64
Are the following true regarding bone mineral density (BMD)?
Is a good indicator of fracture risk in the future
Correct
Is increased by impact exercises lasting 20 minutes for three times a week Correct
Should be performed in patients with a previous history of thyrotoxicosis
Should be performed on all patients using steroids for six months Incorrect answer selected
Should be performed post gastrectomy
Correct
Long term corticosteroid use of more than 7 mg/d for six months can result in osteoporosis.
The question asks if all patients using steroids would need BMD assessed; this is clearly not the case as it
depends on dose.
Treated thyrotoxicosis is not a risk factor for decrease BMD.
Question: 54 of 64
Is it true that the following predispose to osteoporosis?
Excessive alcohol consumption
Correct
Existing thyrotoxicosis
Correct
Hysterectomy with ovarian conservation prior to age 40
Correct
Paget's bone disease

Patients on low dose prednisolone (less than 2.5 mg 1d) for more than 6/12
Oestrogen deficiency is the major cause of osteoporosis with steroid induced the next major cause (daily use
of more than 5 mg prednisolone for more than six months induces osteoporosis).
Hysterectomy is associated with premature ovarian failure.
Question: 55 of 64
In the investigation of post menopausal bleeding, are the following true?
A Pipelle samples more of the endometrium than a Vabra
A Pipelle samples up to 14% of the cavity
Failure to pass a Pipelle occurs in up to 19% of post menopausal women
Correct
Hysteroscopy may fail to detect pathology 3% of the time

Correct
Sonohysterography is more sensitive than hysteroscopy when assessing the endometrium
A Pipelle biopsy samples 4% of the endometrium whereas a Vabra samples around 40%.
Saline hysterography has a sensitivity of 87% and a specificity of 91% whereas hysteroscopy has a
sensitivity of 90% and specificity of 91%.
Question: 56 of 64
Are the following statements true in post menopausal bleeding (PMB)?
Almost 2% will have an ovarian tumour
Correct
Bladder cancer may be responsible for the symptoms in up to 10% of cases Incorrect answer
selected
In developing countries cervical cancer is the commonest malignancy responsible for PMB
Correct
The commonest malignancy is endometrial cancer
Correct
Up to 12% of patients will be found to have a malignancy
Correct
Bladder cancer has been reported in up to 2.5% of patients with PMB.

Interestingly. nearly 2% (1.7%) of women presenting with PMB will be found to have an ovarian tumour.
Up to 90% of cases of post-menopausal bleeding are down to benign pathology which in the majority of
instances is due to atrophic vaginitis but can also be due to polyps and endometrial hyperplasia.
Question: 57 of 64
Which of the following comments regarding normal fertility is/are true?
20% of normal couples will not achieve pregnancy until the second year of unprotected intercourse
75% of women are aware of their mid-cycle discharge
Progesterone production is at its peak around ovulation
The maximum survival time of spermatozoa in the female genital tract at mid-cycle is 24 hours
There has been a significant decline in sperm density in European men since 1950 Correct
For young and healthy heterosexual couples having frequent intercourse, about 85% will be pregnant after
one year of trying and about 93% will be pregnant after two years of trying to conceive.
There is a cyclical variation in the amount of vaginal secretions; it is heavier in the pre-menstrual period,
and also at ovulation.
Whilst oestrogen levels peak around the time of ovulation, progesterone production peaks in the mid luteal
phase.
Spermatozoa can survive in the female genital tract for up to six days but two to three days is most typical.
In 1992 a worldwide decline in sperm density was reported; this was quickly followed by numerous
critiques and editorials. Mean sperm densities were highest in Europe and lowest in non-Western countries.
A decline in sperm density was seen in the United States and Europe but not in non-Western countries.
Question: 58 of 64
Concerning vaginal moniliasis, are the following statements true or false?
Commonly affects pregnant women
Correct
Is a common cause of post-menopausal vaginitis
Is associated with glycosuria
Correct
May be asymptomatic
Correct
Responds to treatment with metronidazole
Patients who are
Diabetic
Pregnant
Immunosuppressed
Taking broad spectrum antibiotics or the combined oral contraceptive pill (COCP)
are susceptible to Candida.

It responds to anti-fungals, for example, fluconazole.
Question: 59 of 64
Does short stature in the human female have a recognised association with the following?
A 45 XO/46 XX mosaic
Correct
Congenital adrenal hyperplasia (CAH)
Correct
Down's syndrome
Correct
Klinefelter syndrome
The androgen insensitivity syndrome (testicular feminisation syndrome) Incorrect answer selected
45 XO Turner's syndrome results in short stature.
Klinefelter's (47XXY) is found only in males.
Patients with testicular feminisation (44XY) do not have short stature.
CAH often has normal stature but may also be small due to early puberty and epiphyseal closure.
Question: 60 of 64
Can the following treatments be used in the condition with which they are paired?
Cisplatin : ovarian carcinoma.
Correct
Clomiphene citrate : resistant ovary syndrome.
Intrauterine device : post-coital contraception.
Correct
LHRH analogue : endometriosis.
Correct
Medroxyprogesterone acetate : menopausal symptoms.
Luteinising hormone-releasing hormone (LHRH) analogues like buserelin are used to 'switch off' pituitary
LH/FSH secretion through positive feedback in the treatment of conditions such as endometriosis.
An intrauterine contraceptive device (IUCD) can be effectively used for post-coital contraception.
Cisplatin and paclitaxel chemotherapy are used as first line chemotherapeutic agents in ovarian carcinoma.
Resistant ovary syndrome is a rare syndrome found in 20% of those with premature ovarian syndrome. It is
characterised by
Amenorrhoea
Endogenous hypergonadotropinaemia, and
Resistance to exogenous gonadotropins.
Histologically there is an almost complete absence of developing follicles.

The exact cause is unknown, and there are several theories including a deficiency of FSH and LH receptors
in the ovary, the presence of antibodies to gonadotropin receptors, and a postreceptor defect. Consequently,
clomiphene would be ineffective.
Clomiphene is used for the induction of ovulation in polycystic ovarian syndrome.
Progestagens are used in conjunction with oestrogens in women with an intact uterus to prevent unopposed
oestrogenic endometrial hyperplasia. However, it is not effective in treating the menopausal symptoms such
as flushing, sweats and vaginal dryness which are oestrogen dependent.
Question: 61 of 64
Regarding Wertheim's hysterectomy, are the following statements true or false?
It can be followed by adjuvant radiotherapy.
It is the treatment of choice for stage III carcinoma of the cervix.
Only palpably enlarged lymph nodes are removed.
Correct
The ovaries can be conserved.
Correct
There is a high incidence of post-operative bladder dysfunction
Correct
Wertheim's (radical) hysterectomy entails the removal of the
Uterus
Upper part of the vagina
Ovaries (usually)
Pelvic ligaments and
Lymph nodes.
This is usually performed in the case of cancer of the cervix, which can spread sideways into these
ligaments and nodes.
Bladder complications, such as
Overflow incontinence
Urinary retention
Loss of bladder sensation and
Detrusor instability
occur because of bilateral disruption of parasympathetic and sympathetic nerve fibres of the bladder and
ureter.
Stage III cervical carcinoma extends out to the pelvic sidewall, and/or involves the distal third of the vagina,
or causes hydronephrosis or a nonfunctioning kidney.
Consequently more extensive surgery and chemotherapy is required for this stage of disease.
Adjuvant chemotherapy may be required following the procedure to improve survival.
Question: 62 of 64
In the Tetralogy of Fallot
The aorta rises from the right ventricles
Correct
The pulmonary artery arises from the right ventricle
Correct
Blood from the right ventricle flows to the left ventricle via the VSD
The left ventricle is grossly enlarged
As much as 75% of the circulatory blood is unoxygenated

Correct
In Tetralogy of Fallot, the aorta originates from the right ventricle and the pulmonary artery is stenosed
resulting in up to 75% of the blood by passing the lungs. Blood from the left ventricle flows to the right
through a VSD, resulting in an enlarged right ventricle.
Question: 63 of 64
Fetal alcohol syndrome is characterised by:
Fetal anomalies in 10% of severe alcohol exposure
Intra-uterine growth retardation
Correct
Altered dermatoglyphics
Correct
Atrial septal defect
Correct
Joint hyperextensibility
High levels of alcohol ingestion during pregnancy can be damaging to embryonic and fetal development. A
specific pattern of malformation identified as the fetal alcohol syndrome has been documented, and major
and minor components of the syndrome are expressed in 1-2 infants/1,000 live births. Both moderate and
high levels of alcohol intake during early pregnancy may result in alterations in growth and morphogenesis
of the fetus; the greater the intake, the more severe the signs. Infants born to heavy drinkers have twice the
risk of abnormality compared with those born to moderate drinkers; 32% of infants born to heavy drinkers
demonstrated congenital anomalies, compared with 9% in the abstinent and 14% in the moderate group. The
characteristics of the fetal alcohol syndrome include:
1. Prenatal onset and persistence of growth deficiency for length, weight, and head circumference.
2. Facial abnormalities, including short palpebral fissures, epicanthal folds, maxillary hypoplasia, micrognathia,
and thin upper lip.
3. Cardiac defects, primarily septal defects.
4. Minor joint and limb abnormalities, including some restriction of movement and altered palmar crease
patterns.
5. Delayed development and mental deficiency varying from borderline to severe. Fetal alcohol syndrome is a
common cause of mental retardation.
The severity of dysmorphogenesis may range from severely affected infants with full manifestations of the
fetal alcohol syndrome to those mildly affected with only a few manifestations. The detrimental effects may
be due to the alcohol itself or to one of its breakdown products. Some evidence suggests that alcohol may
impair placental transfer of essential amino acids and zinc, both necessary for protein synthesis, which
accounts for the intrauterine growth retardation. The management of these infants may be difficult, since no
specific therapy exists. The infants may remain hypotonic and tremulous despite sedation, and the prognosis
is poor. Counselling with regard to recurrence is important. Prevention is achieved by eliminating alcohol
intake after conception.
Question: 64 of 64
Theme:Secondary Amenorrhoea
A Anorexia
B Asherman's syndrome
C Pregnancy
D Menopause
E Pseudocyesis
F Psychogenetic factors
G Sheehan's syndrome
H Stein-Leventhal syndrome
For each case below choose the single most likely diagnosis from the list of options:
An extremely pale looking 28-year-old lady six months following delivery of her first child at which she
suffered a post-partum haemorrhage and whose periods have not returned.
Incorrect - The correct answer is Sheehan's syndrome
Sheehan's syndrome refers to pituitary avascular necrosis usually due to TB or post-partum haemorrhage. In this
case the lady is very pale because of the loss of melanocyte-stimulating hormone (MSH) which is produce by the
pituitary gland.
A 22-year-old lady who looks normal and whose periods have not returned following a dilatation and
curettage for a missed miscarriage at 10 weeks.
Incorrect - The correct answer is Asherman's syndrome
Asherman's syndrome refers to the obliteration of the endometrial cavity and the endometrium from either
destruction by TB or over zealous curetting at the time of miscarriage. This is often treated with oestrogen and
inserting a coil to allow the endometrium to reform in the cavity and to build up.
A 27-year-old lady of Asian origin complaining of hirsutism and no periods for nine months
Incorrect - The correct answer is Stein-Leventhal syndrome
Stein-Leventhal syndrome is another name for polycystic ovarian syndrome and comprises a syndrome that is made
up of various degrees of hirsutism, oligomenorrhoea, insulin resistance and obesity. Patients may present in a
variety of different ways and it is commoner in women of Asian origin particular living in England but may present in
anyone. A family history of insulin resistant diabetes may also be present.
When thinking about secondary amenorrhoea it is important to remember the physiological causes, that is,
pregnancy and menopause.
Conditions of extreme illness usually result in the loss of menstruation although anorexia and hyperexercise
will also cause this.
Pseudocyesis and psychogenic factors may also be associated with secondary amenorrhoea presumably
through a hypothalamic stress response.
Primary vs Secondary amenorrhoea...

Fertility PDF

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Fertility PDF

Uploaded by

Copyright:

Available Formats

Obs & Gynae - Fertility & Gynaecology 1

Obs & Gynae - Fertility & Gynaecology 2

Obs & Gynae - Fertility & Gynaecology 3

Obs & Gynae - Fertility & Gynaecology 4

Incorrect - The correct answer is 5 years

Incorrect answer selected

Cannot be detected by Gram staining

Incorrect answer selected

Causes a rise in the pH of vaginal secretions

Vaginal pH of 4.5 or above

Fifty percent of the women with BV are asymptomatic.

Obs & Gynae - Fertility & Gynaecology 5

The mother has a history of small VSD

The mother was a smoker

Incorrect answer selected

Obs & Gynae - Fertility & Gynaecology 6

The donor twin may have microcardia.

The recipient twin may have large glomeruli.

By definition the twins vary in Hb by > 5g/dl

The surviving twin is at risk of disseminated intravascular coagulation.

Obs & Gynae - Fertility & Gynaecology 7

Congenital anomalies are found in about 1/3 of cases.

There is an association with trisomy 18.

Associated defects may be subtle.

There is an association with Beckwith's syndrome.

Incorrect answer selected

Obs & Gynae - Fertility & Gynaecology 8

It is first detected at the equivalent of 32-38 weeks gestational age.

It may progress extremely rapidly.

Occurs more frequently in infants of diabetic mothers.

The lungs have low compliance.

Incorrect answer selected

Is more common in infants of mothers addicted to narcotics.

Incorrect answer selected

Obs & Gynae - Fertility & Gynaecology 9

Obs & Gynae - Fertility & Gynaecology 10

Obs & Gynae - Fertility & Gynaecology 11

Incorrect - The correct answer is Danazol

Obs & Gynae - Fertility & Gynaecology 12

Incorrect - The correct answer is Vaginismus

Obs & Gynae - Fertility & Gynaecology 13

Incorrect answer selected

Scaphocephaly develops from premature fusion of the coronal suture

Incorrect answer selected

Occipital plagiocephaly is usually due to infant positioning

Scaphocephaly develops from premature fusion of the lamdoid suture

Incorrect answer selected

Scaphocephaly - sagittal suture.

Obs & Gynae - Fertility & Gynaecology 14

Trigonocephaly - metopic suture.

Copyright 2002 Dr Colin Melville

Incorrect answer selected

Square window test

Incorrect answer selected

Copyright 2002 Dr Colin Melville

Obs & Gynae - Fertility & Gynaecology 15

Obs & Gynae - Fertility & Gynaecology 16

Obs & Gynae - Fertility & Gynaecology 17

Obs & Gynae - Fertility & Gynaecology 18

Obs & Gynae - Fertility & Gynaecology 19

An 18-year-old student four days after unprotected intercourse.

Obs & Gynae - Fertility & Gynaecology 20

Obs & Gynae - Fertility & Gynaecology 21