MRCOG Part 1 Hijau
MRCOG Part 1 Hijau
MRCOG Part 1 Hijau
Edited by
Maryam Parisaei MRCOG
Consultant Obstetrician and Gynaecologist,
Homerton University Hospital NHS Foundation Trust, London, UK
Amit Shah MD MRCOG
Consultant in Reproductive Medicine and Surgery,
Homerton University Hospital NHS Foundation Trust, London, UK
The rights of Katherine Andersen, Tara Woodward, Maryam Parisaei and Amit Shah to be identified
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ISBN: 978-1-907816-36-9
JP Medical Ltd is a subsidiary of Jaypee Brothers Medical Publishers (P) Ltd, New Delhi, India
The Membership of the Royal College of Obstetricians and Gynaecologists (MRCOG) remains the
cornerstone for the assessment of knowledge required by trainee doctors in the UK. Passing the
exam is a prerequisite for the progression through the structured training programme, towards the
Certificate of Completion of Training (CCT) and entry on to the Specialist Register. The standard of
the exam remains high and the curriculum is based on UK practice.
The MRCOG Part 1 exam can be taken at any time after graduation and must be passed before
transition from ST2 to ST3 of the training programme. This book aims to provide an exam revision
guide for trainee doctors in ST1 and ST2, and international candidates preparing to sit the exam.
For international graduates often working outside of recognised training programmes it is a
tough exam to pass. Yet many candidates continue to take the exam knowing that success will
demonstrate the acquisition of knowledge to a high standard, which will enhance the treatment of
the women and babies in their care.
The MRCOG Part 1 has changed in the last few years. It has always tested the knowledge-
base in all the basic sciences as they pertain to obstetrics and gynaecology, but a new question
format has been introduced to allow the syllabus to be tested in a more clinically relevant manner.
Doctors planning to take the exam must now learn how to answer both multiple choice questions
(MCQs) and the new single best answer (SBA) format, and for this they require exam technique and
clinical knowledge.
This book contains 550 SBAs and MCQs arranged into individual chapters based on the exam
syllabus. Covering all the basic sciences as well as current RCOG clinical recommended practice,
it provides a comprehensive revision aid with helpful explanations after each question. The book
also offers guidance on other information sources and a suggested reading list. At the back of
the book there are two practice papers for readers to test their knowledge and practise exam
technique.
v
Preface
Passing the MRCOG Part 1 is regarded as the first step in becoming an obstetrician and
gynaecologist. For many candidates, it will be their first postgraduate exam and the task of
passing at first sitting can seem daunting. However, we believe that with appropriate preparation
candidates can feel confident in passing the exam first time.
The new curriculum now combines subject matters from everyday clinical practice as well as
all the basic medical sciences and is much more clinically orientated than before. There is also a
new format with the introduction of single best answer (SBA) questions, the removal of extended
matching questions (EMQs) and the reduced proportion of multiple choice questions (MCQs). This
book reflects both the new curriculum and format.
The 550 questions presented in this book cover the syllabus in a format which mimics the exam
itself. Working through the book will allow trainees to gauge their level and breadth of knowledge
and will highlight topics which need to be concentrated on further. Within the answer sections,
references are made to the latest evidence-based practice, and tables and diagrams are used to aid
in the assimilation of this information.
The philosophy of this book is to provide trainees with an insight into the new assessment
technique of the MRCOG Part 1 and to build confidence by approaching the exam in a systematic
manner. We hope you enjoy working through the questions in this book and wish you best of luck
in the exam.
Katherine Andersen
Tara Woodward
Maryam Parisaei
Amit Shah
April 2012
Acknowledgements
We would like to thank Dr Helen Hammond for her eagerness to review all 550 questions and for
her excellent advice regarding their content.
Thanks also to Dr Simon Tod from Sydney, Australia, who gave much appreciated advice
regarding the book’s statistical content.
Katherine Andersen
Tara Woodward
vii
Exam revision advice
Exam format
The MRCOG Part 1 exam consists of Paper 1 and Paper 2. Each paper consists of 60 single best
answer (SBA) questions and 30 multiple choice questions (MCQs). Each paper must be completed
within two hours and thirty minutes. The SBA and MCQ sections are marked out of 150 marks each.
Katherine Andersen
Tara Woodward
viii
Contents
Foreword v
Preface and acknowledgements vii
Exam revision advice viii
Recommended reading x
Chapter 1 Anatomy 1
Chapter 2 Biochemistry 29
Chapter 3 Embryology 45
Chapter 4 Endocrinology 53
Chapter 6 Genetics 99
Index 347
ix
Recommended reading
Bennett P, Williamson C (eds). Basic Sciences in Obstetrics and Gynaecology: A Textbook for
MRCOG Part 1, 4th edn. Edinburgh: Churchill Livingstone, 2010.
Chamberlain G, Steer P (eds). Turnbull’s Obstetrics, 3rd edn. London: Churchill Livingstone, 2001.
Collins S, Arulkumaran S, Hayes K, et al. Oxford Handbook of Obstetrics and Gynaecology, 2nd edn.
Oxford: Oxford University Press, 2010.
Connor JM. Medical Genetics for the MRCOG and Beyond. London: RCOG Press, 2005.
Fiander A, Thilganathan B (eds). Your Essential Revision Guide MRCOG Part 1. London: RCOG Press,
2010.
Kumar V, Abbas A, Fausto N, Aster J. Robbins and Cotran Pathologic Basis of Disease, 8th edn.
Philadephia: Saunders Elsevier, 2009.
Nelson-Piercy C. Handbook of Obstetric Medicine, 4th edn. London: Informa Healthcare, 2010.
x
Chapter 1
Anatomy
Questions: MCQs
Answer each stem ‘True’ or ‘False’.
1. The following form part of the superior anatomical boundary (pelvic inlet) of
the true pelvis:
A Linea alba
B Sacroiliac joint
C Ischial fossa
D Iliac crest
E Iliopectineal line
8. Rectus sheath:
A The rectus sheath is made up of the aponeuroses of transversus abdominis and
internal oblique
B Below the arcuate line, the posterior rectus abdominis is separated from the
peritoneum by transversalis fascia and connective tissue
C Pyramidalis is external to the rectus sheath
D The rectus sheath contains the ventral rami of lower eight thoracic nerves
E Contains an anastomosis between the internal thoracic artery and superior
epigastric artery
Questions: SBAs
For each question, select the single best answer from the five options listed.
25. Which of the following structures does not pass through the diaphragm?
A Azygos vein
B Cisterna chyli
C Inferior vena cava
D Oesophagus
E Thoracic duct
26. Which vessel provides blood supply to the intestine from the splenic flexure of the
transverse colon to the rectum?
A Inferior mesenteric artery
B Median sacral artery
C Middle colic artery
D Rectal artery
E Superior mesenteric artery
29. A 27-year-old woman has a cervical smear result which shows ‘borderline’
changes.
Which cells line the ectocervix?
A Ciliated cells
B Columnar epithelium
C Cuboidal epithelium
Questions: SBAs 7
32. Which of the following organs is derived from ectodermal neural crest cells?
A Adrenal gland inner medulla
B Adrenal gland outer cortex
C Liver
D Pancreas
E Spleen
33. A 63-year-old woman complains of numbness over her thigh following a radical
hysterectomy for stage IV endometrial carcinoma.
What is the nerve root of the obturator nerve?
A Anterior division L1–L4
B Anterior division L2–L4
C Anterior division L3–L4
D Posterior division L2–L4
E Posterior division L3–L4
B Inguinal ligament
C Obturator internus
D Pectineus
E Sartorius
35. A 32-year-old woman complains of pain in the right buttock. She is 36 weeks
pregnant and has a history of chronic back pain.
Which nerve supplies the gluteus maximus muscle?
A Inferior gluteal
B Internal obturator
C Internal obturator (lateral cutaneous nerve of the thigh)
D Sciatic
E Superior gluteal
36. Following a routine elective caesarean section, the rectus sheath is being sutured.
With regards to the rectus sheath which of the following is correct?
A Arcuate line demarcates the upper limit of the posterior layer of rectus
sheath
B External oblique aponeurosis forms the posterior aspect of the sheath
C Internal oblique aponeurosis always passes in front of rectus abdominis
D Scarpa’s fascia is superficial to Camper’s fascia and the external oblique
E Transversalis fascia lies directly below the rectus sheath
38. What structure does the right ovarian vein empty into?
A Azygos vein
B Inferior vena cava
C Internal iliac vein
D Right renal vein
E Right pudendal vein
39. A 27-year-old woman has a forceps delivery under regional block. She suffers
multiple second degree tears to the lateral vaginal wall.
Questions: SBAs 9
40. Which artery supplies the structures derived from the foregut of the embryo?
A Coeliac trunk
B Inferior mesenteric
C Middle rectal
D Renal
E Superior mesenteric
43. Which of the following arteries is a terminal branch (not paired) of the abdominal
aorta?
A Gonadal
B Median sacral
C Phrenic
D Renal
E Suprarenal
A Bulbocavernosus
B External anal sphincter
C Ischiocavernosus
D Levator ani
E Transverse perineal
47. Which of the following describes the anatomy of the inguinal region?
A The deep inguinal ring lies at the lateral two-thirds of the inguinal ligament
B The deep inguinal ring transmits the ilioinguinal nerve
C The superficial inguinal ring lies below the pubic tubercle
D The superficial inguinal ring transmits the genitofemoral nerve
E The superficial inguinal ring transmits the round ligament
48. Which of the following nerves is transmitted by the superficial inguinal ring?
A Femoral nerve
B Genitofemoral nerve
C Ilioinguinal nerve
D Peroneal nerve
E Sciatic nerve
Answers 11
Answers
1. A False
B True
C False
D False
E True
The female pelvis can be divided anatomically into two broad areas: the false pelvis
and the true pelvis. The false pelvis lies above the pelvic brim and has no obstetric
importance. The true pelvis lies below the pelvic brim and is related to child birth.
The true pelvis comprises an inlet, outlet and cavity. The pelvic inlet (brim) has the
following boundaries: sacral promontory, sacroiliac joints, alae of sacrum, iliopectineal
line, upper border of superior pubic rami and upper border of pubic symphysis.
2. A True
B False
C True
D True
E True
The diameters of the pelvis can be broadly categorised into transverse,
anteroposterior and oblique (Figure 1.1).
Anteroposterior
diameter
3. A False
B True
C True
12 Chapter 1 Anatomy
D True
E False
The pudendal nerve originates from the anterior (ventral) rami of S2, S3 and S4. After
passing between piriformis and coccygeus, it leaves the pelvis through the greater
sciatic foramen. It then crosses the ischial spine with the internal pudendal artery
and re-enters the pelvis through the lesser sciatic foramen. The pudendal nerve
passes medially to the internal pudendal artery (Figure 1.2).
Piriformis
Pudendal nerve
Obturator
internus
Obturator externus
4. A False
B True
C False
D True
E True
Pelvic splanchnic nerves provide parasympathetic innervation to the pelvis and
are derived from the ventral primary rami of S2–S4. They control micturition,
defaecation and erection. The inferior hypogastric plexus is formed from fibres of
the sacral splanchnic nerves, pelvic splanchnic nerves and hypogastric nerves, and
supplies the viscera of the pelvis. The rectal plexus is a posterior division of the
inferior hypogastric plexus. The pudendal nerve gives off the inferior rectal nerves,
before dividing into two terminal branches: the dorsal nerve of the penis/clitoris and
the perineal nerve.
Answers 13
The ilioinguinal nerve is derived from L1 and one of its terminal divisions is the
anterior labial nerve, which supplies the skin of the mons pubis and labia majora.
5. A False
B True
C True
D False
E True
The right ovarian vein drains directly into the inferior vena cava. The left ovarian vein
drains into the left renal vein. The internal pudendal vein drains into the internal
iliac vein and the external pudendal vein drains into the great saphenous vein. The
internal pudendal vein passes through the pudendal canal with the pudendal artery
and nerve. The uterine plexuses lie in the superior angles of the uterus, between the
two layers of the broad ligament. They connect the ovarian and vaginal plexuses
and drain directly into the hypogastric vein. The two other sites of portocaval
anastomosis are in the oesophagus and hepatic circulation.
6. A False
B True
C False
D True
E True
Innervation of the lower limb is from the lumbosacral plexus, which is formed
from the ventral rami of spinal nerves T12–S4. The sciatic nerve is a nerve of the
posterior leg, derived from L4–S3 and contains fibres from anterior and posterior
aspects of the lumbosacral plexus. The tibial nerve is derived from the anterior
division of L4–S3 and is a branch of the sciatic nerve. The tibial nerve passes
through the popliteal fossa and provides branches to the posterior aspect of the
calf, as well as the knee joint. The femoral nerve arises from the dorsal division
of the ventral rami of L2–L4. It passes beneath the inguinal ligament to enter the
thigh, where it then divides into an anterior and posterior division. It provides
innervation to the quadriceps muscle and sartorius, as well as anterior cutaneous
branches.
7. A False
B True
C False
D False
E True
The anal canal is approximately 3 cm long and lies between the anorectal junction
and the anal orifice. The upper two-thirds is lined with cuboidal epithelium
and is supplied by the superior rectal artery. The lower one-third is lined with
14 Chapter 1 Anatomy
non- keratinised stratified squamous epithelium and is supplied by the inferior rectal
artery. At the anal orifice there is a transition to keratinised stratified squamous
epithelium with the presence of sweat glands and hair. Hilton’s line is a white line
which indicates the junction of the keratinised from the non-keratinised epithelium.
The pectinate line is an important landmark embryologically which lies at the
junction of the upper two-thirds and lower one-third. The fibres of pubococcygeus
blend with the internal anal sphincter.
8. A False
B True
C False
D False
E False
The rectus sheath is formed from the aponeurosis of the transversus abdominis,
internal and external oblique muscles. At the lateral margin of the rectus abdominis,
the internal oblique splits into an anterior and posterior layer, passing in front and
behind. In front of the rectus abdominis runs the external oblique aponeurosis and
the anterior layer of internal oblique. Behind the rectus runs the posterior layer of
internal oblique and the transversus abdominis. The aponeuroses of each side meet
at the central linea alba. Below the arcuate line, all aponeuroses pass in front of the
rectus abdominis, meaning that the posterior aspect of the lower third of rectus is
separated from the peritoneum by transversalis fascia and extraperitoneal connective
tissue. The ventral rami of the lower seven thoracic nerves and anastomosis between
the superior and inferior epigastric vessels occurs within the rectus sheath. Where
pyramidalis is present, it lies within the rectus sheath anterior to rectus abdominis.
9. A True
B False
C True
D False
E False
The pudendal canal contains the pudendal nerve, artery and vein. It runs medially
to the obturator internus and is in close contact with the obturator fascia. It runs out
through the greater sciatic foramen and passes laterally to the ischial spines before
passing back in through the lesser sciatic foramen.
10. A True
B True
C False
D True
E False
The urinary bladder is a muscular distensible organ that is located in the pelvis.
The main blood supply to the bladder comes from the superior and inferior vesical
Answers 15
arteries, which are branches of the anterior trunk of the internal iliac artery. There is
also some contribution from the uterine and vaginal arteries. The detrusor muscle
is innervated from the S2–S4 nerve root, but the main contribution is from S3.
The bladder is predominantly under parasympathetic control, from the inferior
hypogastric plexus and the pelvic splanchnic nerves. The sympathetic nervous
system only affects blood vessels in the bladder and has no motor function. The
human bladder is derived in the embryo from the urogenital sinus.
11. A False
B False
C True
D True
E True
The testes are oval glands that have an average length of 4–5 cm and a diameter
of 2–3 cm. They originate embryologically in the abdomen, but descend through
the inguinal canal prior to birth. Each testis is surrounded by the tunica vaginalis,
which is a serous membrane, derived from the peritoneum. Underneath the tunica
vaginalis is a fibrous layer that encapsulates the testis, called the tunica albuginea.
It forms septa that divide each testis internally to form 200–300 lobules. It is within
each of these lobules that the seminiferous tubules are located.
12. A True
B False
C False
D True
E False
Ureters are muscular tubular structures, approximately 25 cm long, which run along
the posterior abdominal wall. They are retroperitoneal through their entire course
and carry urine from the kidneys to the bladder. The ureter begins at the kidney and
descends from the renal pelvis along the medial border of the psoas muscle. From
there, it enters the pelvis and crosses the common iliac artery. In females the ureters
travel in the broad ligament and run under the uterine artery eventually inserting
into the bladder posterolaterally. The openings of the ureters into the bladder are
approximately 2–3 cm apart.
13. A True
B True
C False
D True
E False
The vagina is a muscular elastic tube that extends from the cervix to the vulva. It
is a tubular structure, is approximately 10 cm in length, and lies in a superior and
posterior direction. The anterior wall is shorter than the posterior wall; the anterior
16 Chapter 1 Anatomy
gland has a corresponding vein. The right adrenal vein drains directly into the inferior
vena cava and the left adrenal vein into the renal vein.
20. A False
B True
C False
D True
E True
The adrenal (or suprarenal glands) sit below the diaphragm and above the kidneys.
The left gland has a semi-lunar shape and sits snug proximal to the spleen,
pancreas and stomach. The right triangular adrenal gland sits slightly lower than its
counterpart, making contact with the liver and inferior vena cava (IVC). The outer
cortex of the glands originates from mesoderm and is responsible for corticosteroid
and androgen production. The inner medulla derives from neural crest cells and its
chromaffin cells secrete catecholamines. The glands receive their blood supply from
the suprarenal arteries (superior, middle and inferior). The left suprarenal vein drains
into the left renal vein and the right suprarenal vein drains into the IVC.
21. A True
B True
C False
D True
E True
The inguinal ligament is formed in part from the external oblique aponeurosis. The
inguinal canal passes between the deep inguinal ring and the superficial inguinal
ring. Contents of the inguinal canal include the round ligament, a branch of the
genitofemoral nerve and the ilioinguinal nerve.
22. A True
B False
C False
D True
E False
The boundaries of the femoral triangle are:
• Superiorly: the inguinal ligament
• Laterally: sartorius muscle
• Medially: adductor longus muscle (medial border)
• Floor: adductor longus, pectineus, iliacus and psoas major
• Contents: femoral nerve, femoral vein, femoral artery, lymph nodes and fat
23. A True
B False
Answers 19
C True
D True
E False
The femoral vessels pass beneath the inguinal ligament. The femoral sheath is
produced from the transversalis as the vessels pass inferiorly into the thigh region.
The femoral sheath has the femoral nerve laterally to it. The node of Cloquet is a
lymph node that drains the clitoris and glans penis and it is located in the femoral
canal, which is also situated within the femoral sheath.
24. A True
B False
C True
D True
E False
The major muscles of the posterior abdominal wall are the psoas major, iliacus and
quadratus lumborum. The psoas major originates at the lateral aspects of all five
of the lumbar vertebrae, passing downwards and laterally where it attaches to the
lesser trochanter of the femur. It allows for lateral flexion of the trunk ipsilaterally.
It is innervated by the ventral rami of the lumbar nerves L1–L3 (or L2–L4). Iliacus
originates from the anterior superior iliac spine and also the sacrum. It joins the
psoas major (also inserting at the lesser trochanter of the femur) and they form
iliopsoas, which is the major flexor of the thigh. Iliacus is innervated by the femoral
nerve (L2–L4). Quadratus lumborum originates at the 12th rib and as it descends
becomes broader. It inserts into the aponeurosis of the iliolumbar ligament and
the iliac crest. It flexes laterally and also extends the spinal column, as well as fixing
the 12th rib during inspiration. Psoas minor is only present of 50% of humans,
irrespective of gender.
Level Structure
Caval opening T8 Inferior vena cava
Branches phrenic nerve
Oesophageal opening T10 Oesophagus
Aortic hiatus T12 Aorta
Thoracic duct
Azygos vein
Abdominal
aorta
Ovarian
arteries
Internal External
iliac arteries iliac artery
Answers 21
28. B L1
The ilioinguinal nerve arises from the L1 nerve root along with the larger
iliohypogastric nerve. It travels obliquely across the quadratus lumborum and
perforates the transversus abdominis near the anterior part of the iliac crest. It
travels through part of the inguinal canal, passing through the superficial inguinal
ring. It supplies the mons pubis and labium majus.
30. B Anthropoid
The basic shapes of the pelvis are as follows:
• Gynaecoid pelvis (50%): normal female type, inlet is slightly transverse oval;
sacrum is wide with average concavity and inclination; subpubic angle is 90–100°.
• Anthropoid pelvis (25%): ape-like; anteroposterior (AP) diameters are long;
transverse diameter short; sacrum long and narrow, subpubic angle is narrow.
• Android pelvis (20%): male type, inlet is triangular or heart-shaped with anterior
narrow apex, subpubic angle is narrow < 90°.
• Platypelloid pelvis (5%): flat female type, AP diameter is short, transverse
diameter is long, subpubic angle is wide.
31. D Pubococcygeus
The levator ani muscle is formed by the pubococcygeus, iliococcygeus and
ischiococcygeus. Although considered in three parts, the muscle forms a continuous
sheet, which provides significant support to the pelvic organs.
Pubococcygeus forms the bulk of the levator ani muscle, arising from the back of
the pubis and the white line that runs in front of the obturator canal. Its fibres form
a U-shaped loop which runs around the urethra, vagina and anorectal junction, with
the medial fibres blending with the upper urethra. Intermediate fibres loop around
the vagina, closing the lower end on contraction. Lateral fibres run around the anus,
inserting into the lateral and posterior walls of the anal canal between the internal
and external sphincters.
Iliococcygeus arises from the white line behind the obturator canal and inserts into
the lateral margins of the coccyx.
Ischiococcygeus arises from ischial spine and inserts into the coccyx.
22 Chapter 1 Anatomy
Femoral vein
Sartorius Adductor
longus
the transversus abdominis passes behind; the aponeurosis of the internal oblique
divides into two at the lateral margin, with the anterior lamellae passing in front
of the rectus abdominis and the posterior lamellae passing behind. Scarpa’s fascia
is deep to the Camper’s fascia and superficial to external oblique muscle. See
Figure 1.5 for the anatomy of the rectus sheath above and below the arcuate line.
The transversalis fascia forms the layer below the rectus sheath.
External oblique
Internal oblique
Transversus
abdominis
Peritoneum Transversalis
fascia
24 Chapter 1 Anatomy
37. E
Ureters cross close to the bifurcation of the common
iliac vessels
The ureters leave the kidney and travel inferiorly and medially along the psoas
muscle. They run along the posterior pelvic brim and cross anteriorly to the
bifurcation of the common iliac vessels. They continue posteroinferiorly and turn
medially at the ischial spines. They then run in the base of the broad ligament where
they are crossed by the uterine artery (water under the bridge). The ureter passes the
lateral vaginal fornix and enters the bladder.
level of the pelvic brim. Each artery supplies its respective ovary and fallopian tube,
anastomosing with the uterine arteries. Arterial and venous supply to the ovaries
follow a similar course, however, the right ovary receives its venous supply from the
right ovarian vein, which reaches the inferior vena cava and the left ovary is supplied
by the left renal vein.
44. C Ischiocavernosus
The perineal body (or central tendon of the perineum) is a midline structure formed
of fibromuscular tissue found between the vagina and the anus in females. The
external anal sphincter, transverse perineal muscles, bulbocavernosus muscle
and the levator ani muscles all insert into the perineal body. The ischiocavernosus
muscle is a muscle of the superficial pouch of the perineum. Lying between the
perineal membrane and the subcutaneous tissue, it arises from the inferior ischial
ramus and compresses the crus clitoris, hence promoting clitoral erection. See
Figure 1.6 for the anatomy of the perineum.
Ischial spine
Pubic tubercle
Obturator
foramen Pubic
symphysis
Ischium Pubis
47. E
The superficial inguinal ring transmits the
round ligament
The deep inguinal ring is situated at the midpoint of the inguinal ligament. It can
be located by finding the midpoint between the anterior superior iliac spine and
the pubic tubercle. The superficial inguinal ring lies just above, and lateral to the
pubic tubercle. The deep and superficial rings mark the entrance (deep ring) and exit
(superficial ring) to the inguinal canal.
The canal’s boundaries are:
• Anterior wall: external oblique aponeurosis, with lateral reinforcement from the
internal oblique
• Posterior wall: transversalis fascia, with the conjoint tendon (internal oblique and
transversus abdominis) providing medially
• Superiorly: internal oblique
• Inferiorly: inguinal ligament
Running through the canal is the round ligament in females and the spermatic cord
in males. The ilioinguinal nerve passes through the superficial inguinal ring only,
having travelled down the lateral abdominal wall between the internal and external
oblique muscles. See Figure 1.8 for the anatomy of the inguinal canal.
Answers 27
Internal
oblique
muscle
External
oblique
muscle
Inguinal ligament
Femoral vessels
Questions: MCQs
Answer each stem ‘True’ or ‘False’.
2. Glycogen:
A Is a branched polymer of glucose
B Has its main stores in muscle
C Is broken down by glucose-6-phosphatase
D Its synthesis (i.e. glycogen synthase) is inhibited by adrenaline
E Levels in the blood stream are highest in the evening
4. Fat metabolism:
A Fat can be metabolised anaerobically
B Fat can be used by the brain as a source of fuel
C Oxidation of fatty acids takes place in the mitochondria
D Beta-oxidation of fatty acids is controlled by supply of substrate
E The liver can synthesise fatty acids to ketone bodies
5. Arachidonic acid:
A Is a second messenger
B Is an amino acid
C Is a precursor of thromboxane
D Is inhibited by aspirin
E Is converted to prostaglandins
30 Chapter 2 Biochemistry
8. Phenylketonuria:
A Is an autosomal dominant condition
B Is caused by a defect in the metabolism of tyrosine
C Is detected using the Kleihauer–Betke test in newborns
D Untreated, results in severe intellectual impairment
E Can be managed using a protein-rich diet
9. Regarding steroidogenesis:
A Progesterone is the precursor of pregnenolone
B Cholesterol is the precursor of all other steroids
C Corticosterone is converted to aldosterone
D Pregnenolone is formed in cellular mitochondria
E Testosterone is a precursor of oestradiol
10. Prostaglandins:
A Are hydrophilic
B Are synthesised from arachidonic acid
C Are antagonised by non-steroidal anti-inflammatory drugs
D Consist of 18 carbon atoms
E Bind to G protein-coupled receptors
Questions: SBAs 31
Questions: SBAs
For each question, select the single best answer from the five options listed.
11. Which condition is caused by the failure to mineralise newly formed osteoid?
A Osteomalacia
B Osteopaenia
C Osteopetrosis
D Osteoporosis
E Paget’s disease of bone
13. Which enzyme is involved in the rate-limiting step of the glycolysis pathway?
A Glucokinase
B Glucose 6-phosphate
C Hexokinase
D Phosphofructokinase
E Phosphoglucose isomerase
D Tryptophan
E Tyrosine
16. A 24-year-old woman is admitted via the emergency department with persistent
hyperemesis of pregnancy. She is now feeling very unwell and appears dehydrated.
Her blood pressure is 110/60 mmHg, heart rate 100 beats per minute, SpO2 98% on
room air and a respiratory rate of 20 breaths per minute.
Which is the most likely acid-base disorder in this patient?
A Metabolic acidosis
B Metabolic alkalosis
C Mixed metabolic alkalosis and respiratory acidosis
D Respiratory acidosis
E Respiratory alkalosis
17. Following the birth of their second child with severe developmental delay, a
couple is seen by a clinical geneticist. Genotyping suggests a rare autosomal
recessive condition caused by a defect in the normal functioning of the citric acid
cycle.
Which of the following is not an intermediate of the citric acid cycle?
A Alpha-ketoglutarate
B Acetyl coenzyme A
C Citrate
D Oxaloacetate
E Succinyl coenzyme A
18. Which of the following describes the appearance of sister chromatids during the
anaphase of mitosis?
A Alignment along the cell’s horizontal plane
B Alignment along the cell’s vertical plane
C Alignment at one pole
D Separation to diagonal poles
E Separation to opposite poles
19. A 12-year-old boy has gross developmental delay of unknown cause. On physical
examination, he is noted to have macro-orchidism, prominent ears and a large
forehead. He is seen by a clinical geneticist who suspects Fragile X syndrome and
wishes to perform genotyping.
Which of the following laboratory techniques is used to detect DNA sequences?
A Eastern blotting
B Northern blotting
C Northwestern blotting
D Southern blotting
E Western blotting
Questions: SBAs 33
20. A 58-year-old woman has recently been diagnosed with type 2 diabetes mellitus.
As part of her routine care, her general practitioner checks and her fasting
cholesterol levels. She is found to have a mildly raised total cholesterol level with a
raised serum low-density lipoprotein level.
Which of the following describes the function of low-density lipoproteins?
A Transport of cholesterol from the body’s tissues to the liver
B Transport of cholesterol from the liver to tissues around the body
C Transport of chylomicrons from the liver to elsewhere in the body
D Transport of triglycerides from the intestine to other tissues for storage
E Transport of triglycerides from the liver to elsewhere in the body for oxidation
21. An infant is born at term by normal vaginal delivery. When the baby is 18 days
old, he is brought to the emergency department by his parents. He is vomiting,
severely dehydrated and appears to be underweight. The paediatricians diagnose
a salt-wasting crisis and are concerned that he has a form of congenital adrenal
hyperplasia.
What hormone deficiency is characteristic of this disorder?
A Cholesterol
B Cortisol
C Dihydrotestosterone
D Oestradiol
E Testosterone
34 Chapter 2 Biochemistry
Answers
1. A False
B True
C True
D True
E False
The net yield of the glycolytic pathway (Figure 2.1) per molecule of glucose
is 2 molecules of nicotinamide adenine dinucleotide (NADH) and 2 molecules
of adenosine triphosphate (ATP). The first step of glycolysis involves
phosphorylation of glucose to glucose 6-phosphate by hexokinase. An
isoenzyme of hexokinase, glucokinase is used in the liver, but has a lower affinity
for glucose. This reflects the liver’s role in maintaining blood sugar levels. In
allosteric inhibition, the shape of the enzyme is altered by the substrate binding
to a site separate from the usual binding site. This leads to a reduction in the
usual substrate binding and therefore the activity of the enzyme. The ATP
allosterically inhibits phosphofructokinase.
2. A True
B False
C False
D True
E False
Glucose is stored in the body in the form of glycogen. It is stored in the liver and to
a lesser degree, in muscles. Glycogen stores can be mobilised if glucose levels in
the bloodstream are low and the main enzyme of glycogen breakdown is glycogen
phosphorylase. Levels of glycogen do fluctuate, however, there is no diurnal pattern
and levels reflect oral intake.
3. A False
B True
C True
D True
E True
The tricarboxylic acid (TCA) cycle takes place in the mitochondria of eukaryotic cells.
One of the regulating factors is the availability of substrate.
Each turn of the TCA cycle produces:
• 3 NADH + 1 FADH2
• 1 Guanosine-triphosphate (GTP)
• 2 CO2
where NADH is nicotinamide adenine dinucleotide and FADH2 is flavin adenine
dinucleotide.
The GTP can be converted to adenosine triphosphate (ATP). The NADH and FADH2
donate their electrons to the electron transport chain, which produces ATP.
Acetyl coenzyme A is produced from the metabolism of carbohydrates, proteins
and fats and is converted into energy through the tricarboxylic acid cycle. Four
pairs of hydrogen atoms are released per turn of the cycle, which then feed into
the electron transport chain. Each hydrogen pair then reduces one atom of oxygen
and by doing so releases three molecules of ATP. See Figure 2.2 for the TCA cycle
(or Krebs cycle).
36 Chapter 2 Biochemistry
Acetyl-CoA NADH
Oxaloacetate 4C Citrate 6C
NAD+
NADH
Malate 4C
Isocitrate 6C
NAD+
Fumarate 4C
CO2 NADH
FAD
FADH2 α-ketoglutarate 5C
Succinate 4C NAD+
CO2
GDP+P NADH
GTP Succinyl CoA 4C
4. A False
B False
C True
D True
E True
Metabolism of fats can only occur in the presence of oxygen and never occurs under
anaerobic conditions. The brain has an absolute requirement for glucose as a fuel
and, in the presence of starvation, ketone bodies may provide 75% of the energy
supply. Oxidation of fatty acids occurs in the mitochondria. Fatty acids freely diffuse
over the cell membrane and use the enzyme carnitine palmitoyltransferase to access
the mitochondria. The β-oxidation of fatty acids produces acetyl coenzyme A, which
may then be used as a substrate in the tricarboxylic acid cycle. Synthesis of ketone
bodies may occur in the liver in the presence of starvation. During starvation, the
acetyl coenzyme A produced by the oxidation of fatty acids may be channelled into
ketogenesis, rather than into the tricarboxylic acid cycle.
5. A True
B False
C True
D False
E True
Arachidonic acid is a fatty acid attached to cellular membrane phospholipids by
esterification. Freed from the phospholipids by the action of phospholipase A2,
arachidonic acid has a series of roles. It is the precursor of the eicosanoids, i.e.
prostaglandins, procyclins, and the thromboxanes, which have a wide variety
Answers 37
allow for DNA repair, or in irreparable cases induce apoptosis. Genetic mutations
involving both p53 alleles are associated with the development of cancer. BRCA1
is a DNA repair protein that repairs breaks in DNA’s double strands. pRb, the
retinoblastoma protein, is another tumour suppressor protein that inhibits cells
from entering the ‘S’ phase. Ras proteins are involved in regulation of cell signalling
and are considered a proto-oncoprotein. Myc is a transcription factor which
facilitates the progression of the cell cycle. Over expression of both Ras and Myc is
associated with cancer development.
8. A False
B True
C False
D True
E False
Phenylketonuria is a congenital autosomal recessive disorder, associated with a
mutation of a gene found on chromosome 12. It results in the inability to metabolise
the essential amino acid phenylalanine into tyrosine, owing to a deficiency of the
enzyme phenylalanine hydroxylase. Elevated levels of phenylalanine lead to an
accumulation of its by-products, such as phenylacetate and phenylpyruvate, with
devastating consequences. Further metabolic disturbance is caused by the deficiency
in tyrosine. Phenylketonuria is associated with severe intellectual impairment if
untreated, and therefore all newborns in the UK are screened for the condition in the
first week of life.
The Guthrie test involves taking a spot of blood, which is placed on a paper disc. The
disc is then placed with bacteria, which overgrows in the presence of the high levels
of phenylalanine. Treatment strategies for individuals with phenylketonuria include
a lifelong diet of foods low in phenylalanine and pharmaceuticals, which aim to
reduce phenylalanine.
9. A False
B True
C True
D True
E True
Steroids are organic compounds, which all consist of a common core of 20 carbon
atoms arranged into four rings with varying side-chains. Three of these carbon rings
are cyclohexanes and contain six carbon atoms, whereas the remaining ring consists
of five carbon atoms and is cyclopentane.
Steroidogenesis is the synthesis of steroids from the common precursor
cholesterol into other forms of steroids. The conversion of cholesterol, which itself
contains 27 carbon atoms, to other steroids is catalysed by a series of enzymes.
The first product of steroidogenesis is pregnenolone, which is produced in cellular
Answers 39
11. A Osteomalacia
Pregnancy is associated with increased levels of parathyroid hormone, calcitriol and
calcium. Higher concentrations of calcium are absorbed from the gut. Calcium and
phosphate are transferred to fetal circulation by active transport. See Table 2.1 for
conditions associated with abnormalities of bone.
Table 2.1 Disorders of the bone and their typical serum biochemistry
13. D Phosphofructokinase
Glycolysis is the metabolic process that occurs within all aerobic and anaerobic
cells and produces two molecules of pyruvate from one molecule of glucose. This
process of glucose oxidation also generates a gain of two molecules of ATP and
two molecules of NADH. Phosphofructokinase is the enzyme that converts fructose
6-phosphate to fructose 1,6-biphosphate. This irreversible step is considered
the rate-limiting step of glycolysis. In aerobic conditions the generated pyruvate
then enters the tricarboxylic acid cycle (Figure 2.2) within the mitochondria and
subsequently generates ATP in a process of oxidative metabolism.
14. B Pyruvate
Glycolysis is the metabolic pathway that converts glucose into pyruvate and takes
place in the cytoplasm of the cell. Glycolysis forms a sequence of 10 reactions,
involving intermediary compounds at each step, which can provide entry points
into the pathway. This metabolic pathway is common to both aerobic and anaerobic
forms of respiration. In aerobic respiration, pyruvate then enters the tricarboxylic
acid cycle, which takes place within the mitochondria. In anaerobic conditions, the
pyruvate obtained from glycolysis is reduced to lactate via the action of lactate
dehydrogenase.
15. E Tyrosine
Essential amino acids are those that cannot be synthesised directly and therefore
must be obtained through dietary intake. Non-essential amino acids are
Answers 41
those that can be synthesised without the need for dietary supplementation
(Table 2.2).
poles of the cell. Following this separation there is breakdown of the parent cell’s
nuclear membrane, which then reforms around each separate set of chromosomes.
Cytokinesis describes the separation of the cytoplasm and marks the final step in the
formation of the daughter cells.
20. B
Transport of cholesterol from the liver to
tissues around the body
Lipoproteins form the basis of the transport of fats around the body. All
lipoproteins consist of both fats and proteins in a complex consisting of a
hydrophilic outer surface and a hydrophobic core. Low-density lipoproteins (LDLs)
predominantly consist of cholesterol and cholesterol esters and they transport
cholesterol from the liver to tissues around the body whose cells are expressing
the LDL receptor. LDLs are often referred to as ‘the bad cholesterol’ due to their
association with atheromatous change (blood vessels may also express LDL
receptors).
High-density lipoproteins (HDLs) are the smallest of the lipoproteins and are protein
and cholesterol-rich. HDLs ‘collect’ cholesterol from cells which are then sequestered
into its hydrophobic core and are carried to the liver (and steroid producing organs
such as the ovaries), where their cholesterol is released through the action of HDL
receptors. Very low-density lipoproteins (VLDLs) are produced in the liver and
comprise of predominantly triglycerides and cholesterol; in the blood these VLDLs
are converted to LDLs. Chylomicrons are responsible for transporting dietary fats,
predominantly in the form of triglycerides from the small intestine to tissues, such as
the liver and skeletal muscle for usage.
21. B Cortisol
Congenital adrenal hyperplasia (CAH) is used to describe a series of autosomal
recessive conditions characterised by a deficiency in cortisol production (and
Answers 43
Questions: MCQs
Answer each stem ‘True’ or ‘False’.
Questions: SBAs
For each question, select the single most appropriate answer from the five options
listed.
6. Which one of the following constitutes the parameters for a normal sperm count?
10. Which of the following has the correct association regarding development of
urogenital system?
A Genital fold – clitoris
B Genital tubercle – labia minora
C Ureteric bud – urinary bladder
D Mesonephric ducts – vagina
E Metanephros – kidney
Questions: SBAs 47
11. Which of the following statements best describes the development of the cardiac
system?
A Fetal circulation includes two umbilical veins
B The ligamentum venosum is a remnant of the umbilical vein
C The heart is developed from endodermal cells
D The cardinal vein runs into the sinus venosus
E Cardiac pulsations are visible from the 34th day after conception
13. Which of the following statements best describes the development of the
urogenital system?
A Sex cords are developed from coelomic epithelium
B Sex differentiation is present 35 days after fertilisation
C Myometrial walls are present in the fetal uterus by the 5th month
D Reproductive organs are developed from paraxial mesoderm
E In female sex organ development, the upper part of the gubernaculum
becomes the round ligament
48 Chapter 3 Embryology
Answers
1. A False
B True
C True
D False
E False
The trilaminar disc consists of the three germ cell layers: ectoderm, endoderm and
mesoderm, and is formed at the region of the primitive streak. This forms during the
3rd week of development. There is a higher rate of growth of the ectoderm layer at
each end of the disc, which changes the shape of the disc into a more oval nature.
The process of neurulation refers to the development of the nervous system and
involves the rounding of the neural plate with development of the cranial and
caudal ends. The primitive streak is a depression in the caudal end of the disc and
is usually evident by the end of the second week of development. The notochord
provides the longitudinal axis for the embryo and becomes the vertebral column.
The anterior neuropore (cranial) closes at day 24 and the posterior neuropore
(caudal) closes at day 25.
2. A True
B True
C True
D False
E False
Pharyngeal arches are responsible for forming the lower part of the face and the
neck, and they develop from mesoderm. There are six pharyngeal arches, but the
fifth arch regresses. (Table 3.1)
3. A True
B False
C True
D False
E False
The urogenital system develops from mesoderm. The renal system develops from
the nephrogenic cord. There are three parts to the embryonic urinary system that
appear at different points in development. They all have a role in excretion and all
develop at week 4.
• Pronephros: limited function
• Mesonephros: functions from week 6–10
• Metanephros: functions at week 12
Answers 49
The mesonephric bud develops during the 5th week from the ureteric bud. It has
an excretory role for approximately 4 weeks; however, it regresses by week 10. The
permanent kidney develops from the metanephros and by the end of week 12, urine
is produced.
4. A False
B False
C False
D True
E True
The embryonic alimentary system is broadly divided into the foregut, midgut and
hindgut. Each part has a separate blood supply. Table 3.2 shows the division of the
alimentary system.
5. A True
B True
C False
D False
E True
Amniotic fluid volumes are approximately 50 mL at 12 weeks, and increases to about
one litre towards the end of pregnancy. Fetal skin cells undergo keratinisation at
about 25 weeks of pregnancy and prior to this, fluid arises by transfer across the skin.
Amniotic fluid is produced by fetal excretion in urine, with contribution from lung
secretions and amniotic membrane secretions. During the first trimester, the amniotic
50 Chapter 3 Embryology
fluid is mainly composed of water, with some electrolytes. From the second trimester
composition of the fluid changes with addition of lipids, carbohydrates and proteins.
Amniotic fluid is more acidic than the maternal blood.
6. C
On average an ejaculate will have a volume of 2–5 mL seminal fluid. The average
sperm count in this fluid is 60 x 106/mL and a low sperm count would be associated
with a count of < 15 million/mL. Motility describes the action and movement of the
sperm, and the proportion of which have forward motion. The progressive motility
should be at least 40%. Another parameter that is used to classify sperm counts is
the morphology. It is normal to have some abnormal spermatozoa; the minimum
acceptable percentage of semen with normal morphology is 4%.
• Mesoderm
• Ectoderm
Each of these layers give rise to different parts of the embryo as summarised in
Table 3.3.
9. E Extraembryonic mesoderm
It is the cells of the extraembryonic mesoderm that develop into the chorionic villi.
The neural crest gives rise to the nervous system and melanocytes. Endoderm is
one of the germ cell layers and produces the gastrointestinal tract, respiratory tract
and endocrine organs. The primitive streak develops by the end of the second
week in the bilaminar embryonic disc and functions to determine symmetry of the
developing embryo. The hypoblast is a part of the inner cell mass and lies beneath
the epiblast. It gives rise to extraembryonic endoderm.
The ductus venosus is a variation of the fetal circulation which directs blood from
the umbilical vein into the inferior vena cava. This allows oxygenated blood from
the placenta to bypass the liver. The cardiac system is developed from angiogenic
mesoderm cells. The anterior cardinal vein forms the internal jugular vein and
combined with the common cardinal vein forms the superior vena cava. The cardinal
vein does run into the sinus venosus.
Questions: MCQs
Answer each stem ‘True’ or ‘False’.
9. Phaeochromocytoma:
A Is a cause of hypertension in < 1% of cases
B Has a triad of symptoms: sweating, palpitations and headaches
C Is linked with Carney complex
D Has an association with multiple endocrine neoplasia-1
E Treatment is with a cardioselective beta-blocker followed by an alpha-blocker,
phenoxybenzamine
19. Prolactin:
A Is a peptide hormone
B Has a molecular weight of 44,000
C Is produced by the anterior pituitary gland
D Production increases in response to dopamine release
E Has a similar structure to growth hormone
21. Oxytocin:
A Is stored in the hypothalamus
B Acts via a G-protein-coupled receptor
C Is a nonapeptide
D Is responsible for milk production
E Has an identical structure to vasopressin
Questions: SBAs
For each question, select the single best answer from the five options listed.
34. A 16-year-old girl is seen in the gynaecology outpatient department with primary
amenorrhoea and excessive facial hair growth. Examination reveals normal
genitalia, apart from an apparently large clitoris. Differential diagnosis includes
congenital adrenal hyperplasia (CAH).
CAH (21α-hydoxylase deficiency) is characterised by which of the following?
A Hypertension, hypokalaemia and hyponatraemia
B Hypertension, hyperkalaemia and hyponatraemia
C Hypotension, hyperkalaemia and hypernatraemia
D Hypotension, hyperkalaemia and hyponatraemia
E Hypotension, hypokalaemia and hyponatraemia
35. A 27-year-old woman is seen in the antenatal clinic. She suffered from
hyperemesis gravidarum in the first trimester and routine thyroid function tests
have revealed abnormalities.
Which of the following is a recognised change in regulation of thyroid function in
pregnancy?
A Decelerated rates of T4 and T3 degradation and production
B Decreased basal metabolic rate
C Increased total T4 and T3 in the first trimester
D Increased thyroid-stimulating hormone
E Reduced plasma iodine concentration in early pregnancy
36. During her pregnancy a 38-year-old woman is diagnosed with gestational diabetes
requiring insulin treatment at 28 weeks of gestation.
Which of the following statements bests describes the function of human placental
lactogen?
A It enhances amino acid transfer across the placenta
B It has insulin-like properties
C It increases glucose utilisation
D It increases insulin sensitivity in pregnancy
E It is a growth hormone antagonist
39. A 28-year-old woman is referred to the gynaecology clinic with primary infertility.
On examination, she has a round face, prominent stretch marks on her abdomen
and hirsutism.
Which of the following is not a feature of Cushing’s syndrome?
A Diabetes insipidus
B Depression
C Irregular menstrual cycles
D Osteoporosis
E Weight gain
40. A 26-year-old woman is referred to the gynaecology clinic with abdominal pain
and amenorrhoea. You suspect she may have Cushing’s syndrome and decide to
send her for further tests.
Which of the following tests would be suitable for confirmation of the diagnosis?
A Adrenocorticotrophic hormone levels
B High dose dexamethasone suppression test
C Low dose dexamethasone suppression test
D Short synacthen test
E Urinary free cortisol
45. A 60-year-old woman with a chronic disease is admitted to hospital acutely unwell.
She has severe diarrhoea and vomiting. She is hypotensive with a blood pressure of
85/45 mmHg. You suspect, she has Addison’s disease.
Which of the following is a recognised cause of Addison’s disease?
A Diabetes insipidus
B HIV
C Hyperparathyroidism
D Pregnancy
E Sarcoidosis
52. A 21-year-old woman is started on the mini pill. She asks you about the possible
side effects of progesterone.
Questions: SBAs 63
54. A 34-year-old woman undergoes regular ultrasound scans for follicle tracking
having been started on clomiphene treatment.
Which of the following statements most appropriately describes the mature
ovarian follicle?
A Its development is primarily controlled by luteinising hormone
B It is surrounded by theca cells
C It is usually the only primary follicle to develop during each cycle
D It produces progesterone
E It reaches a diameter of 20–30 mm prior to rupture
55. A 23-year-old woman is seen in the gynaecology clinic after an ultrasound scan
reveals multiple cysts on both ovaries. She also complains of irregular menstrual
cycles and has been trying to conceive for over 1 year.
Which of the following lead to clinical manifestations of polycystic ovarian syndrome?
A Decrease in oestradiol levels
B Decrease in prolactin
C Decrease in testosterone and androstenedione
D Increase in fasting insulin
E Increase in sex hormone binding globulin
Answers
1. A True
B True
C True
D False
E True
Human chorionic gonadotrophin (hCG) is a glycoprotein which is thought to have
thyrotrophic activity. This may cause some increased thyroid activity and therefore
lead to a reduction in the levels of thyroid-stimulating hormone. Thyroxine-binding
globulin is responsible for binding thyroxine in circulation, along with transthyretin
and albumin. Hyperemesis gravidarum is a common condition of early pregnancy,
associated with a rise in β-hCG. It is associated with an abnormally high level of free
thyroid hormones and reduced thyroid stimulating hormone, and therefore thyroid
function tests should be performed on women presenting with this condition.
2. A False
B True
C False
D True
E True
Parathyroid hormone (PTH) is a polypeptide hormone secreted by the chief cells
of the parathyroid glands. There are four parathyroid glands which develop from
the pharyngeal pouches during embryological development. The superior glands
develop from the third pouch and the inferior glands from the fourth pouch. They
are located under the capsule at the posterior area of the thyroid gland and the
blood supply is via the thyroid arteries. The gene for PTH is located on chromosome
11; with PTH being synthesised as a large preprohormone of 115 amino acids. It is
cleaved to give a biologically active 84 amino acid peptide and then stored in the
Golgi apparatus of the cytoplasm of the cell.
3. A False
B False
C True
D True
E True
Prolactin is a long chain polypeptide hormone. It is produced by the anterior
pituitary and is responsible for lactation. The milk ejection reflex is caused by
oxytocin, produced by the posterior pituitary in response to suckling. Prolactin is
released from the anterior pituitary gland in response to thyrotrophin-releasing
Answers 65
Diagnosis of Addison’ disease is via the short Synacthen test. A cortisol level is taken
30 minutes after receiving a bolus of ACTH.
Waterhouse–Friderichsen syndrome is a haemorrhage into the adrenal cortex as
a result of fulminant meningococcaemia. Other causes of adrenal haemorrhage
include coagulopathic states, shock and pregnancy-associated causes.
9. A True
B True
C True
D False
E False
Phaeochromocytoma is a catecholamine producing tumour of the
neuroendocrine cells of the adrenal medulla. It is a rare cause of hypertension,
being responsible for approximately 1% of cases. It may be an autosomal
dominant inherited condition. Most phaeochromocytoma are found unilaterally
in the adrenal medulla. Symptoms may include headache and ‘a sense of
impending doom’ associated with increased blood pressure. Multiple endocrine
neoplasia (MEN) is a group of genetic tumour syndromes. Phaeochromocytoma
is found in MEN-2a, along with medullary thyroid cancer and parathyroid
hyperplasia. MEN-1 comprises parathyroid hyperplasia, pituitary adenoma
and pancreatic tumours. Treatment can be surgical or medical; however,
blood pressure control is usually necessary prior to operative management.
Alpha-blockade is given by phenoxybenzamine and 24 hours later a
cardioselective beta-blocker is given.
10. A False
B True
C True
D True
E False
The overall function of insulin is to decrease hepatic output of glucose. This occurs
via the following mechanisms:
• Promote glycogen synthesis
–– Increase glycogen synthetase (muscle and liver)
–– Inhibit glycogen phosphorylase
• Decrease gluconeogenesis
• Suppress lipolysis
–– Inhibit triglyceride lipase
–– Increase fatty acid synthetase
• Suppress ketogenesis
–– Inhibit carnitine palmitoyltransferase
–– Increase acetyl coenzyme A carboxylase
68 Chapter 4 Endocrinology
11. A True
B False
C True
D False
E True
Three main oestrogens are:
• Oestrone (E1)
• Oestriol (E2)
• Oestradiol (E3)
Oestrone is the main oestrogen postmenopause and is weaker than oestradiol.
12. A False
B True
C True
D False
E True
The production of steroid hormones by the ovary depends on the menstrual cycle.
Progesterone is produced by the ovarian theca and granulosa cells and is produced
mainly during the luteal phase of the menstrual cycle. During the follicular phase
of the cycle it is mainly oestrogen that is produced. Testosterone is produced by
the theca only. Oestradiol, the end product of steroidogenesis, is produced only by
the granulosa cells. In the ovarian follicles, theca cells have receptors for luteinising
hormone (LH) and not follicle-stimulating hormone (FSH). Granulosa cells have
receptors for FSH and for LH later on.
13. A False
B True
C False
D True
E False
Oogonia fill the ovaries during fetal life and these primordial germ cells divide by
mitosis until shortly before birth. No further oocytes are produced after birth and at
this time each female has approximately one million oocytes. Primary oocytes are
contained in the ovary of the fetus and arrested after the first meiotic division until
ovulation. Although the oogonia are arrested in the first prophase stage of meiosis,
they are surrounded by a layer of granulosa cells. Oocytes surrounded by this
protective layer are known as primordial follicles and are located in the cortex of the
ovary. When the luteinising hormone surge occurs, the dominant follicle completes
this first meiotic division to become a secondary oocyte. The first polar body is found
in the ovum and contains half the chromosomes. Second meiotic division is not
completed until fertilisation.
Answers 69
14. A False
B True
C False
D True
E True
Follicle-stimulating hormone (FSH) is a glycoprotein hormone produced by
the anterior pituitary. FSH has a molecular weight of 30,000 and is comprised
of 204 amino acids. FSH is similar in composition to other anterior pituitary
gland hormones including thyroid-stimulating hormone and human chorionic
gonadotrophin, and all of these hormones are made of an α subunit with a specific
β subunit. FSH acts on the ovaries and the testes to promote gametogenesis, and it
also has a role in hormone synthesis. FSH is raised in menopausal women because of
the reduction in circulating oestradiol.
15. A True
B True
C False
D False
E True
Follicle-stimulating hormone (FSH) and luteinising hormone (LH) are both
produced by the anterior pituitary gland and are glycoprotein hormones.
Like thyroid-stimulating hormone (TSH), they consist of α- and β-subunits;
the α subunit is identical in all three hormones. Both FSH and LH are released
in response to pulses of gonadotrophin-releasing hormone (GnRH) from the
hypothalamus.
FSH stimulates receptors on the granulosa cells of the female ovarian follicles to
produce oestrogen; increased levels of oestrogen act via a negative feedback on the
hypothalamus, thus leading to a decrease in the release in FSH.
Raised levels of oestrogen from the growing ovarian follicle lead to an increase in
pulses of GnRH and a subsequent surge in LH, which in turns leads to ovulation at
around day 14 of the menstrual cycle.
FSH levels are raised after the menopause, when decreasing levels of oestrogen, as
a consequence of ovarian atresia, work via a positive feedback loop, thus increasing
FSH levels in an attempt to stimulate oestrogen production.
16. A True
B False
C True
D False
E True
70 Chapter 4 Endocrinology
18. A False
B True
C True
D False
E False
Hormone replacement therapy (HRT) aims to reduce symptoms of the menopause
as well as reduce osteoporosis. HRT can be administered topically, orally,
transdermally and via implants. The main constituent of all forms of HRT is
oestrogen. In order to prevent endometrial hyperplasia because of unopposed
oestrogen levels, all women with a uterus should also receive a form of HRT which
contains a form of progestogen. Alternatively another source of progesterone can
be administered, e.g. the levenorgestrel intrauterine system intrauterine system. In
women who have had a hysterectomy an oestrogen only HRT is suitable. Synthetic
progestogens are structurally different from progesterone but have similar activity.
Testosterone can improve the libido in postmenopausal women. Side effects of
HRT include breast tenderness, bloating as well as headaches, nausea, depression
and subjective reports of weight gain. Tibolone is a synthetic steroid drug that is
classified as hormone replacement therapy. It is a chemically inert substance until it
is absorbed when it then becomes active.
19. A True
B False
C True
D False
E True
72 Chapter 4 Endocrinology
D False
E True
Unsurprisingly prolactin levels rise during pregnancy. Maternal iodine levels fall due
to the combined effects of increased urinary excretion and fetal demand. Relaxin
has a variety of sources; in males it is produced by the prostate (present in semen). In
females, relaxin is produced by the corpus luteum and the breast and in pregnancy
by the placenta. It may have a role in ligament relaxation during pregnancy and
cervical dilatation. Relaxin levels rise during the first trimester of pregnancy then fall
at the end of the trimester only to peak again close to delivery. Follicle-stimulating
hormone levels fall in pregnancy. Thyroid-stimulating hormone levels rise in
pregnancy; this may be partly due to the thyrotrophic properties of human chorionic
gonadotrophin.
29. A False
B True
C False
D False
E False
All levels of adrenal function are increased in pregnancy, and this includes
corticotrophin releasing factor. Synthesis of both cortisol and cortisol-binding
globulin is increased. Levels of aldosterone, angiotensin II and renin increase. The
trophoblast increases the amount of ACTH produced with overall maternal levels
remaining stable.
30. A False
B False
C True
D True
E False
Calcium homeostasis is markedly changed during pregnancy, because of changes
in maternal physiology and the need to meet fetal demand. Serum albumin
concentrations decrease in pregnancy because of the haemodilutional effects of
volume expansion, leading to a reduction in levels of albumin-bound calcium.
Unbound calcium levels remain the same. To meet fetal calcium demand there
is increased production of parathyroid hormone and subsequent increases in
1,25-dihydroxycholecalciferol. Fetal plasma levels of calcium are higher than of the
mother reflecting active transport across the placenta.
31. A True
B False
C False
76 Chapter 4 Endocrinology
D True
E True
Overall thyroid function is grossly unchanged during pregnancy, however, there
are some notable changes. Synthesis of thyroid-binding globulin by the liver is
increased; total levels of T3 and T4 increase as a result of this rise. Levels of free T4 do
fall in the second and third trimester. Thyroid-stimulating hormone (TSH) levels show
some fluctuation in the first trimester with increasing levels of human chorionic
gonadotrophin (hCG) leading to a fall in overall TSH levels due to hCG’s thyrotrophic
activity. During pregnancy, the thyroid gland increases its uptake of iodine from the.
32. A False
B True
C True
D False
E False
Growth hormone (GH) is a peptide and consists of 191 amino acids. The locus for the
growth hormone gene is on chromosome 17. It has a molecular weight of around
21,000 daltons and is structurally similar to both prolactin and human placental
lactogen. It is secreted from the anterior pituitary gland somatotrophs in response
to GH releasing hormone. Somatostatin is a direct inhibitor of GH. GH release
stimulates the synthesis of insulin like growth factors and it stimulates lipolysis and
gluconeogenesis.
Insulin growth factors stimulate bone growth and protein synthesis in muscles.
33. A True
B False
C True
D True
E False
Growth hormone (GH) is secreted by the somatotrophs of the anterior pituitary
gland. Its release is stimulated and inhibited by hormones produced the
hypothalamus, growth hormone releasing hormone and somatostatin respectively.
The action of growth hormone is principally one of the anabolism and this is
reflected in its role in lipolysis and its anti-insulinic properties.
GH is secreted in higher levels during puberty when more frequent pulsatile release
occurs. The growth promoting actions of GH are mediated by insulin-like growth
factor-1.
3β-hydroxysteroid
dehydrogenase
21-hydroxylase
11β-hydroxylase
18-hydroxycortiosterone
Aldosterone
35. E
Reduced plasma iodine concentration in
early pregnancy
During the first trimester, the increased renal blood flow and glomerular filtration
rate lead to increased level of iodine clearance from the plasma. Patients with
already low levels of iodine are predisposed to developing goitre. In the first
trimester rising levels of human chorionic gonadotrophin (hCG) to lead to a
reduction in serum levels of thyroid-stimulating hormone (TSH) as it has thyrotropic
properties, because of the structural similarity of hCG to TSH. Pregnancy is
associated with increased thyroid binding globulin because of increased liver
production, with subsequent elevation of total T4 and T3.
Low dose dexamethasone suppression test involves giving 0.5 mg/6 h orally for
48 hours and then measuring plasma cortisol at 0 hour and 48 hours. This test is
used to confirm the diagnosis. Localisation of the disease is done via the high dose
dexamethasone test (complete or partial suppression indicates Cushing’s disease)
and testing plasma adrenocorticotrophic hormone level.
41. C Hypokalaemia
Cushing’s syndrome is a disorder of high serum cortisol, which has many causes
and has been discussed previously. The most common cause is exogenous
administration of steroid hormones. Cushing’s disease refers to Cushing’s syndrome
caused specifically by a tumour of the pituitary gland, which secretes large amounts
of adrenocorticotropic hormone, leading to high cortisol. Patients may have
hyperglycaemia and insulin resistance, causing diabetes mellitus. All of the above
are potential features of Cushing’s syndrome, except for hyponatraemia. Findings
of hyperglycaemia and hypokalaemia may be accompanied by hyponatraemia as a
result of increased aldosterone levels.
Table 4.2 Levels of cortisol and adrenocorticotrophic hormone (ACTH) in various pathologies
Cortisol ACTH
Normal Low – midnight Not raised
High – 0800
Primary adrenal failure Low High
Steroid therapy Variable Variable (may be normal or very low)
Cushing’s (adrenal origin) High Low (undetectable)
Cushing’s (pituitary origin) High High
Cushing’s (ectopic ACTH High Very high
production)
45. B HIV
Addison’s disease is caused by primary adrenocortical insufficiency, most commonly
with an autoimmune cause. It has an incidence of approximately 1/100,000 and is
therefore relatively rare. Autoimmunity may lead to antibodies against the adrenal
gland and may be associated with other autoimmune diseases, including thyroid
disease, pernicious anaemia and diabetes. Other causes include tuberculosis and
acute bleeding into the adrenal gland (Waterhouse–Friderichsen syndrome).
HIV is now a common cause of Addison’s disease in areas, where HIV is prevalent.
Sarcoidosis is not classically known to cause Addison’s disease.
47. A Dopamine
Catecholamines are derived from the amino acid tyrosine and have a half life in the
circulation of a few minutes. The first step is the conversion of tyrosine to L-dopa by
the enzyme tyrosine hydroxylase, and it is this reaction which forms the rate limiting
step in the synthetic pathway. Dopamine is the first catecholamine to be produced,
followed by norepinephrine and epinephrine. Catecholamines are degraded by
catechol-O-methyltransferase (COMT) or monoamine oxidases (MAO).
48. B Hyperglycaemia
Phaeochromocytoma is a tumour that produces catecholamines and is a rare cause
of resistant hypertension. It is usually found in the adrenal medulla, however 10%
are found elsewhere. Other symptoms include palpitations and psychological
symptoms. Investigation may reveal glycosuria in up to one-third of patients.
Hyperglycaemia is caused primarily by the stimulation of lipolysis because
of catecholamine production. Stimulation at β-adrenergic receptors leads to
glycogenolysis and gluconeogenesis. Thirty per cent of patients have glycosuria
during attacks. Investigations to establish a diagnosis of phaeochromocytoma
include 24-hour urine collection for vanillylmandelic acid which is a catecholamine
metabolite. Hyperkalaemia and basophilia are not typically associated with
phaeochromocytoma.
50. E Somatostatin
Insulin is a peptide hormone synthesised and secreted by the β cells of the islet of
Langerhans of the pancreas. It is secreted as a prohormone which gets converted
to an active hormone by proteolytic cleavage of the C-peptide. Insulin is the main
hormone controlling the blood glucose levels. Insulin is released in response to
increased amino acids, free fatty acids and gastric hormone which are released in
response to eating, including cholecystokinin, gastrin and secretin. Insulin release is
inhibited by adrenaline and somatostatin.
Coagulation
• Increase circulating coagulating factors, including plasminogen, factors II, VII,
IX, X. Increase antithrombin III
Lipids
• Increase high-density lipoproteins
• Increase triglycerides
• Reduce low-density lipoproteins
Gastrointestinal
• Reduce bowel motility
Structural
• Stimulate endometrial growth
• Increase discharge and lubrication
• Increase bone formation
• Promote formation of secondary sexual characteristics
Fluid balance
• Increase salt and water retention
56. C Hyperprolactinaemia
Sex hormone-binding globulin (SHBG) is synthesised in the liver. 80% of
testosterone is bound to SHBG, 19% to albumin and 1% is unbound. Biological
effects of circulating androgens depend primarily on the unbound fraction. Its
production is decreased by androgens and insulin. On the other hand, oestrogen
increases the production of SHBG and hence hirsutism is improved by taking the oral
contraceptive pill and during pregnancy.
Chapter 5
Statistics and
epidemiology
Questions: MCQs
Answer each stem ‘True’ or ‘False’.
1. Standard deviation:
A Is the square root of the variance
B 50% of the data set lies within one standard deviation from the mean
C 95% of the data lies within two standard deviations from the mean
D Cannot be used for a data set with a skewed distribution
E One standard deviation is equal to the mode
4. In a sample of 10,000 women the age at the delivery of their first child showed
a normal distribution. The mean age at delivery of their first child was 29 years
old, with a standard deviation of 2 years.
A Two standard deviations from the mean is 33 years old
B The variance is 3 years
C No primiparous woman would be older than 40 years of age
D The median age for a primiparous woman would be 29 years
E The standard error of the mean is 0.02
86 Chapter 5 Statistics and epidemiology
Questions: SBAs
For each question, select the single best answer from the five options listed.
11. What is the World Health Organisation’s definition of the perinatal mortality rate?
A The number of deaths in the 1st week of life per 1,000 live births
B The number of stillbirths and deaths in the first week of life per 1,000 live births
C The number of stillbirths and deaths in the first week of life per 10,000 live
births
D The number of stillbirths and deaths in the first week of life per 100,000 live
births
E The number of stillbirths and deaths in the first 28 days of life per 1,000
deliveries
12. The Eighth Confidential Enquiry into Maternal Deaths in the United Kingdom
defines maternal mortality as:
A The number of deaths per 1000 pregnancies
B The number of deaths per 100,000 pregnancies
C The number of direct and indirect deaths per 100,000 mortalities
D The number of direct and indirect deaths per 10,000 mortalities
E The number of direct and indirect deaths per 100,000 pregnancies
13. Within what time frame does the Centre for Maternal and Child Enquiries
(CMACE) consider maternal death to have occurred?
A During pregnancy
B During pregnancy or within 28 days of the end of the pregnancy
C During pregnancy or within 42 days of the end of the pregnancy
D Within 14 days of the end of the pregnancy
E Within 42 days of the end of the pregnancy
14. An early pregnancy unit undertakes a study to look at the average serum β-human
chorionic gonadotrophin (β-hCG) level of women presenting to their unit with
vaginal spotting over a 2-month period. The data collected has a normal distribution.
The following values are obtained:
• Mean = 500 IU/L
• N = 200
• Variance = 16
88 Chapter 5 Statistics and epidemiology
15. An antenatal clinic undertakes a month long study looking at the diastolic blood
pressure of women at their antenatal booking visit. The data collected has a normal
Gaussian distribution.
The following values are obtained:
N = 93
Mean diastolic blood pressure = 82 mmHg
Variance = 9
What is the standard deviation of the data set?
A 2
B 3
C 5
D 12
E 18
16. One hundred women with postmenopausal bleeding have pelvic ultrasound scans
to measure endometrial thickness and have a pipelle biopsy taken.
The findings of the scan – normal or thickened endometrial thickness – and the
subsequent histology of the Pipelle biopsies – normal or showing endometrial
cancer – are shown in the table below.
What is the sensitivity (to the closest per cent) of the pelvic scan in detecting
endometrial cancer?
A 25%
B 55%
C 83%
D 91%
E 98%
17. One hundred women with postmenopausal bleeding have pelvic ultrasound scans
to measure endometrial thickness and have a pipelle biopsy taken.
Questions: SBAs 89
The findings of the scan, normal or thickened endometrial thickness, and the
subsequent histology of the Pipelle biopsies, normal or showing endometrial
cancer, are shown in the table below.
Total 12 88 100
What is the specificity (to the closest per cent) of the pelvic scan in detecting
endometrial cancer?
A 25%
B 55%
C 83%
D 91%
E 98%
19. A study was designed to look at the relative risk of women with gestational diabetes
mellitus (GDM) who delivered babies with a birth weight of over 4.5 kg. The
study looked at all births in the Grace Maternity Unit over a period of 1 year and
classified whether the woman had GDM or not, and whether their baby weighed
more or less than 4.5 kg.
What is the relative risk of women with GDM delivering a baby weighing > 4.5 kg in
this study?
A 0.05
B 0.1
C 0.4
D 8
E 150
90 Chapter 5 Statistics and epidemiology
Answers
1. A True
B False
C True
D False
E False
Standard deviation is a measure of the scatter of the sample data around the mean.
When data has a normal distribution, it is acceptable to consider the mean and the
median to be equivalent. When there is a normal distribution, 68.1% of the data set
will fall within one (+/–) standard deviation from the mean and 95.4% of the data
set will sit within two (+/–) standard deviations from the mean (Figure 5.1). The
standard deviation may be calculated by taking the square root of the variance.
The standard deviation may used for a skewed data set; however, it is likely to be
of limited use and interquartile ranges may be of more use. In order to obtain an
accurate standard deviation for skewed data, it is advisable to apply logarithmic
transformation.
68.2%
95.4%
3σ 2σ 1σ 1σ 2σ 3σ
M
2. A True
B False
C False
D True
E True
Parametric data is essentially numerical data. It may be continuous, i.e. β-human
chorionic gonadotrophin levels, or discrete, e.g. length of hospital stay. Non-
parametric data may be ordinal data, e.g. first, second and third prizes in a
competitive sport, or nominal data, e.g. Rhesus status being negative or positive.
Parametric tests make a number of assumptions including that of a normal
distribution. Parametric tests have more power than non-parametric tests, therefore
we can have more confidence in their robustness and ability to find a statistically
Answers 91
3. A True
B False
C True
D False
E True
Screening tests are widely used as a means of identifying individuals who are at
a high-risk of having or developing a disease or condition. Antenatal screening
of pregnant women to assess the likelihood of their current pregnancy of being
affected by a common trisomy, such as Trisomy 21, is an example of an effective
screening programme. Screening tests should be widely available and should only
used for either treatable conditions or in circumstances where the result allows
affected individuals to make a decision on how to proceed, e.g. the termination of a
pregnancy affected by a trisomy. Screening tests must be easily reproducible, cost-
effective and acceptable to the population at risk. A screening test does not provide
a final diagnosis; however, it must have a high sensitivity and specificity.
Programme Appraisal Criteria: Criteria for appraising the viability, effectiveness and appropriateness of a
screening programme. UK National Screening Committee. www.screening.nhs.uk/criteria
4. A True
B False
C False
D True
E True
This data set shows a normal Gaussian distribution. On this basis, it is fair to assume
that the median, mode and mean for the data set will be the same. Standard
deviation (SD) is a measure of the scatter of the data set from the mean. In a data
set with a normal distribution 68.2% of a data set will lie within one SD from the
mean, whereas 95% of the sample will lie within approximately two (1.96) SDs from
the mean. Variance is a measure of the extent to which each observation in the data
set deviates from the data set mean. Variance may be calculated by squaring the
standard deviation:
Variance = (SD)2
The standard error (SE) of the mean estimates how close the mean of the data set is
to the mean of the population. The SE of the mean can be calculated by dividing the
SD by the square root of the sample size:
5. A True
B False
C False
D False
E True
A data set with a normal distribution may also be described as having a Gaussian
distribution. Pictorially a normal distribution may be represented using a bell-shaped
curve, reflecting its unimodal properties. Within a normal distribution the majority
of the sample set lie around the mean, giving the distribution a symmetrical shape.
The mean and the median values are the same within a sample with a normal
distribution. The population, from which the data set was taken, can be approximated
by a normal distribution. The standard deviation (SD) is a measure of the spread of the
data set around the mean. Approximately 68% of the data set in a normal distribution
sits within one SD from the mean, whereas approximately 95% of the data set sits
within two SDs from the mean.
6. A False
B True
C True
D True
E False
The statistical test used to analyse a set of data must be carefully chosen and is
dictated by the type of data, how it was obtained and the sample size. Parametric
tests have greater power than non-parametric tests. Parametric tests make the
assumption that the data has a normal distribution, whereas non-parametric
tests do not. Parametric tests can only be used on parametric data, i.e. interval
data. Ordinal and nominal data is classified as non-parametric data and can only
be assessed using non-parametric statistical tests. Student's t-test is a simple and
straightforward test that can be used to compare the means of two sample groups.
The t-test can be performed on paired or unpaired parametric data. Two equivalent
tests that can be used on non-parametric data are the Mann–Whitney U test
and the Wilcoxon Rank Sum test. The Mann–Whitney U test may also be used on
non-parametric skewed data. The Chi-square test is a non-parametric test and may
be used with categorical data. Fisher’s exact test is also a non-parametric test used
for categorical data; however, it can be used for smaller sample sets.
Greenhalgh T. How to read a paper: Statistics for the non-statistician. I: Different types of data need
different statistical tests. BMJ 1997; 315:364.
7. A True
B True
C False
Answers 93
D True
E True
The standard error of the mean (SEM) is a measure of how close the sample mean
of a data set is to the population mean (from which that sample has been taken
from). The SEM is also known as the standard deviation of the mean. The SEM can be
calculated by dividing the standard deviation by the square root of the sample size.
The smaller the value obtained for the SEM, the closer the sample mean lies to the
population mean. Further, the larger the sample size, the more representative the
sample is of the population, and therefore the more accurate and, in theory smaller,
the SEM.
SEM = s ÷
Where; s = standard deviation, n = sample size.
8. A True
B False
C True
D False
E False
Risks of a procedure should be explained in a way that is most understandable
by the patient. The use of numerical aids may be helpful. For some patients, the
estimation of risk may be usefully explained using ratios, e.g. ‘1 in 1000’ rather than
as percentages, e.g. ‘0.1%’.
Valid consent for sterilisation cannot be obtained whilst the woman is having a
caesarean section, unless counselling has previously taken place and provisional
consent has already been given.
Royal College of Obstetricians and Gynaecologists. Obtaining Valid Consent. Clinical Governance Guide 6.
London: RCOG, 2008.
9. A False
B True
C True
D False
E True
The 8th report of the Confidential Enquiries into Maternal Deaths in the United
Kingdom classified causes as maternal death directly related, indirectly related or
unrelated to pregnancy. Indirectly related causes are those that were not the direct
result of obstetric complications but were made worse due to the physiological
changes associated with pregnancy. Both conditions that were diagnosed prior to
or during pregnancy can be classified as indirectly related causes. In the current
report, as in recent previous reports, cardiac disease was the predominant indirectly
94 Chapter 5 Statistics and epidemiology
11. B
The number of stillbirths and deaths in the first week
of life per 1,000 live births
The World Health Organisation currently defines the perinatal mortality rate as the
number of stillbirths and deaths in the first week of life per 1,000 live births (in a given
period). It should not be confused with neonatal mortality, which is the number of
deaths in the first completed 28 days of life per 1,000 live births. Perinatal mortality can
be an important contributor to the overall neonatal mortality rate of a population.
World Health Organisation. Health Status Statistics: Mortality. Neonatal mortality rate (per 1000 live
births). http://www.who.int
12. C
The number of direct and indirect deaths
per 100,000 mortalities
The Eighth Confidential Enquiries into Maternal Deaths in the United Kingdom
defines maternal mortality as the number of direct and indirect deaths per 100, 000
mortalities. Direct causes of maternal mortality are those that result from obstetric
complications and include sepsis, haemorrhage, pre-eclampsia/eclampsia and
amniotic fluid embolism. Indirect causes are those that are not caused by obstetric
complications but were made worse due to the physiological changes associated
with pregnancy. These indirect causes may include conditions that were pre-existing
or were diagnosed during pregnancy. Indirect causes of maternal mortality include
conditions such as cardiac disease, diabetes, epilepsy and suicide.
Centre for Maternal and Child Enquiries (CMACE). Saving Mothers’ Lives: Reviewing Maternal Deaths to
Make Motherhood Safer: 2006–2008. The Eighth Report on Confidential Enquiries into Maternal Deaths in
the United Kingdom. BJOG 2011;118:1–203.
Answers 95
13. C
During pregnancy or within 42 days of the end
of the pregnancy
According to the Centre for Maternal and Child Enquiries (CMACE) a maternal
death is one that has occurred during pregnancy or within 42 days of the end of
the pregnancy. The cause of the death should be related to pregnancy or, if due to
a disease process, be of a nature that the condition had been made worse due to
the physiological changes associated with pregnancy. Accidental deaths are not
included. Deaths may be due to direct or indirect causes. Direct causes are those that
are of a direct obstetric nature, i.e. eclampsia, as opposed to indirect causes which do
not have a direct obstetric cause but relate to conditions which have become more
severe in pregnancy.
Centre for Maternal and Child Enquiries (CMACE). Saving Mothers’ Lives: reviewing maternal deaths to
make motherhood safer: 2006–2008. The Eighth Report on Confidential Enquiries into Maternal Deaths in
the United Kingdom. BJOG 2011;118:1–203.
14. C 4
The standard deviation of a sample is merely a measure of the scatter of the data
set around the mean. The variance is a measure of how far each observation within
the sample varies from the mean. Knowledge of the basic formula used to calculate
standard deviation is key to answering this question. The variance can be calculated
by taking the square root of the variance. There are other formulas that can be used
to calculate the standard deviation but from the limited information given this
simple formula should be used.
Worked answer:
Standard deviation = square root of the variance
Variance = 16
Square root of 16 = 4
Therefore, the standard deviation = 4
15. B 3
The standard deviation of the data set is a measure of how much the data is
scattered from the data set mean. All the information required to calculate the
standard deviation for the data set is given. The simple calculation of taking the
square root of the variance is all that is required to obtain the standard deviation.
Any other values given are distracters and can be ignored.
Worked answer:
Standard deviation = square root of the variance
Variance = 9
Square root of 9 = 3
Therefore the standard deviation = 3
96 Chapter 5 Statistics and epidemiology
16. C 83%
The sensitivity of a test, in this case the pelvic ultrasound, refers to the proportion of
individuals with the disease in question who were correctly identified by the test. In
this study, this can be considered as the proportion of women who were found on
Pipelle biopsy to have endometrial cancer, who were correctly identified as having
an abnormal pelvic ultrasound. In order for a test to be a useful investigation the
specificity should be as close to 100% as possible. Sensitivity can be calculated
by taking the number of subjects diagnosed with the condition using the initial/
screening test, divided by the total number of the all individuals diagnosed with the
condition (whether detected by the screening test or not). To give a percentage the
result is multiplied by 100.
Worked answer:
Sensitivity = endometrial cancer (with abnormal ultrasound) / endometrial cancer
(with abnormal ultrasound) + endometrial cancer (with normal ultrasound) x 100
10/(10 + 2) = 10/12 = 0.83
0.83 x 100 = 83%
17. E 98%
The specificity of a test refers to the proportion of individuals who were confirmed
not to have the disease who were correctly identified as normal by the test. In this
scenario, it refers to the proportion of individuals without endometrial cancer who
had a normal pelvic ultrasound scan. In similarity to sensitivity, ideally the specificity
of a test should be as close to 100% as possible. Specificity can be calculated by
dividing the number of individuals without the condition who had a normal result
from the initial screening test by the total number of individuals without the
condition (including those who initially had an abnormal initial test).
Worked answer:
Specificity = not diagnosed with endometrial cancer (with normal ultrasound) / not
diagnosed with endometrial cancer (with normal ultrasound) + not diagnosed with
endometrial cancer (with abnormal ultrasound) x 100
80/(80 + 2) = 80/82 = 0.98
0.98 x 100 = 98%
Loong T. Understanding sensitivity and specificity with the right side of the brain. BMJ 2003; 327:716.
18. B
To assess the extent to which current practice
meets a defined set of standards
It is important to be able to distinguish the difference between research and audit.
Both are integral to the advancement of medical knowledge and clinical practice. Of
the statements given for this question only the stem ‘to assess the extent to which
current practice meets a defined set of standards’ is a valid aim of audit. All of the
Answers 97
other stems actually refer to aims of research studies. Audit should occur regularly
within a clinical setting to assess how practice standards are being met and the need
to implement strategies for improvement. The process of audit is described as a
continuous cycle, starting with defining the standards of the area of interest, collecting
data, making an assessment of current practice and whether it meets the standards,
followed by identifying and implementing any required changes in practice.
Wade D. Ethics, audit, and research: all shades of grey. BMJ 2005; 330:468
Hardman E, Joughin C. Clinical Audit: What it is and what it isn't. In: FOCUS on Clinical Audit in Child and
Adolescent Mental Health Services. London: Royal College of Psychiatrists, 1998. http://www.rcpsych.ac.uk
19. D 8
Calculating relative risk is a means of quantifying the risk of an event, or a disease
relative to exposure to a contributory factor. A calculated risk of an event/condition
equal to one indicates that there is no difference between those exposed to the
factor and those who were not. A relative risk of less than one suggests that the
exposure group is less likely to develop the condition than the non-exposure,
whereas a relative risk of greater than one indicates that the risk of condition is
increased in the exposure group relative to the non-exposure group. For this study,
the calculated relative risk of women with gestational diabetes mellitus (GDM), in
this study, delivering a baby weighing > 4.5 kg was eight. This indicates that women
with GDM had eight times the risk of having a baby weighing > 4.5 kg. Table 5.1 sets
out the groups for calculation of relative risk.
Questions: MCQs
Answer each stem ‘True’ or ‘False’.
1. Concerning chromosomes:
A Each consists of two identical chromatids
B They are best visualised during interphase
C The short arm of a chromosome is also known as the ‘q’ arm
D Humans have 23 pairs of autosomal chromosomes
E The centromere is the meeting point of two chromatids
6. Regarding aneuploidies:
A Trisomy 16 is the most common trisomy in miscarried fetuses
B Monosomy X is incompatible with life
C Individuals with triple X have multiorgan abnormalities
D Noonan’s syndrome is caused by trisomy of chromosome 12
E The majority of trisomies follow a non-disjunction event at meiosis 1
Questions: SBAs 101
Questions: SBAs
For each question, select the single best answer from the five options listed.
8. A 32-year-old woman is 15 weeks pregnant with her second pregnancy. She opts
to have antenatal screening and has blood taken as part of the quadruple test.
The result shows reduced levels of α-fetoprotein and unconjugated oestriol with
elevated β-human chorionic gonadotrophin.
Which of the following is the most likely explanation for the screening results:
A Down’s syndrome
B Edwards’ syndrome
C Multiple pregnancy
D Neural tube defect
E Normal pregnancy
11. A 29-year-old woman seeks genetic counselling as she has a number of her female
relatives who have had either breast or ovarian cancer. Both her mother and her
sister have been diagnosed with breast cancer. DNA sequencing subsequently
shows that she carries a mutated form of the BRCA1 gene.
Via which mode of inheritance is the BRCA1 gene mutation transmitted?
A Autosomal dominant inheritance
B Autosomal recessive inheritance
C Mitochondrial inheritance
D X-linked dominant inheritance
E X-linked recessive inheritance
12. A 34-year-old woman delivers a male baby with Down’s syndrome. Chromosomal
analysis following his birth is suggestive of familial Down’s syndrome.
What chromosomal event best describes the aetiology of Familial Down’s
syndrome?
A Microdeletion
B Nonsense mutation
C Reciprocal translocation
D Robertsonian translocation
E Triplet repeat expansion
13. A couple are both known to carry the trait for a haemoglobinopathy. They decline
any invasive testing when they conceive their first pregnancy. At an anomaly scan
at 20 weeks’ gestation the fetus is found to have severe hydrops. In utero death
occurs at 22 weeks' gestation.
What is the most likely cause of the fetal demise?
A Alpha-thalassaemia with deletion of 4α-globin genes
B Beta-thalassaemia major
C Glucose-6-dehydrogenase deficiency
D Haemoglobin H disease
E Sickle cell disease
Answers 103
Answers
1. A True
B False
C False
D False
E True
Chromosomes consist of long strands of DNA which have been elaborately folded
and coiled. Within the strands of DNA are sequences which are genes. In eukaryotic
cells, they are found in the cell nuclei, where the DNA material is packaged as
chromatin. Each chromosome consists of two identical chromatids which are
held together in the midline at the centromere. The shape of chromosomes may
be described according to the position of the centromere. The short arm of a
chromosome is known as the ‘P’ arm, whereas the long arm is known as the ‘Q’ arm.
Humans have 22 autosomal chromosome pairs and one pair of sex chromosomes
in each cell. Chromosomes are best visualised in the metaphase of mitosis. Giemsa
staining may be used to aid visualisation of gene rich areas, which aids chromosome
identification in a process called G-banding. See Figure 6.1 for the basic structure of
a chromosome.
Short arm
Centromere
Q
Long arm
Chromatid Chromatid
2. A False
B False
104 Chapter 6 Genetics
C True
D False
E True
Cystic fibrosis (CF) is an autosomal recessive condition affecting exocrine function.
CF is typically found in Caucasian populations and is considered a life-limiting
condition. It is often associated with manifestations such as severe lung disease,
pancreatic insufficiency and infertility.
CF is caused by a defect in the cystic fibrosis transmembrane conductance regulator
(CFTR) gene found on chromosome 7. This leads to a defect in the CTFR protein
which normally acts as a chloride channel. There is defective transport of chloride
ions across epithelial cell membranes and an accumulation of intracellular sodium
leading to an excess of thick secretions on mucosal surfaces. CF is caused by a large
number of mutations in the CFTR gene; however, the most commonly identified
defect is a deletion of the 508th codon of the gene, leading to the absence of a
phenylalanine residue. This mutation is usually denoted as ΔF508.
3. A True
B True
C False
D True
E False
Fragile X is inherited by X-linked dominant inheritance, caused by defect in the FMR1
gene. X-linked dominant conditions can affect both males and females; as males
(XY) contribute the Y chromosome to their male offspring they cannot pass on their
defective X chromosome to their sons, however all of their daughters inherit their X
chromosome.
Duchenne’s muscular dystrophy shows an X-linked recessive inheritance; the
defective gene is carried on the X chromosome, leading to males inheriting the
one defective X chromosome from their mother expressing the condition. Female
offspring who inherit one defective X chromosome act as carriers only due to
the presence of two X chromosomes. Other X-linked recessive conditions include
haemophilia A, Christmas disease (haemophilia B) and glucose-6-phosphate
dehydrogenase deficiency. Prader–Willi syndrome is not an X-linked condition and
is associated with a deletion of the paternally derived chromosome 15. Turner’s
syndrome affects females and is an abnormality of the sex chromosomes, typically
due a loss of a Barr body leading to monosomy X.
4. A True
B True
C True
D False
E False
Answers 105
5. A True
B True
C True
D True
E True
Nuchal translucency refers to the measurement of the subcutaneous fluid at the
back of the fetal neck using ultrasound. Increased nuchal translucency thickness,
when measured between 11 and 14 weeks’ gestation, has been associated with a
number of chromosomal abnormalities and structural defects. Down’s syndrome is
the most commonly referred cause of increased nuchal thickness. Used alongside
the serum markers used in the combined test, data obtained from nuchal
translucency measurement is capable of identifying 90% of fetuses affected by
Down’s syndrome. Fetuses with Patau’s syndrome and Edwards’ syndrome may also
have an increased nuchal thickness, as do female fetuses affected by the monosomy
Turner’s syndrome. Noonan’s syndrome is an autosomal dominant condition which
may be first detected by ultrasound in fetuses with a normal karyotype alongside
nuchal oedema and pleural effusions. In addition to the syndromes described above
there is a strong association between increased nuchal thickness and major cardiac
abnormalities.
106 Chapter 6 Genetics
6. A True
B
False
C
False
D
False
E
True
Aneuploidy refers to an abnormal number of chromosomes and can occur both to
autosomes and the sex chromosomes. The majority of trisomies occur following
a non-disjunction event which occurs in the meiotic division. The most common
trisomy found in miscarried fetuses is trisomy 16 which is incompatible with life.
Trisomy 21 is the most common trisomy compatible with life. Babies with trisomies
13 and 18 have a considerably shortened life expectancy, with the majority not
surviving infancy. Individuals with a trisomy of the X chromosome typically have
normal lives and their aneuploidy is often not diagnosed. The loss of an autosome,
i.e. a monosomy of a chromosome, is not compatible with life; however, fetuses
affected by the monosomy of the X sex chromosome, i.e. Turner’s syndrome, can
survive (albeit with a high incidence of miscarriage). Noonan’s syndrome is an
autosomal recessive condition associated with mutations of four genes leading to
multiple organ defects.
Connor JM. Medical Genetics for the MRCOG and Beyond. London: RCOG Press, 2005.
7. D Trisomy 18
This baby has Edwards’ syndrome, also known as trisomy 18. The syndrome is
caused by an extra copy of chromosome 18 due an error in meiotic dysjunction.
In addition to a true trisomy 18, individuals may be mosaic for trisomy 18, i.e. they
have some cells with an extra copy of chromosome 18 because of a translocation
defect. Trisomy 18 can be detected as part of antenatal screening such as the
quadruple test, however in the absence of antenatal care it may not be detected
until delivery. Both polyhydramnios and oligohydramnios may be observed in these
pregnancies, the former as a possible indicator of defective fetal swallowing, and
the latter reflecting abnormalities in the renal tract. There may intrauterine growth
restriction. Fetuses affected by trisomy 18 typically have cardiac abnormalities of
varying degrees of severity. The appearance of the baby typifies many of the features
of a baby with trisomy 18. Other associated features include rocker-bottom feet,
micro penis, radial aplasia and low-set ears. There is gross delay in psychomotor
development and the rare individuals who survive infancy typically have severe
intellectual disability.
8. A Down’s syndrome
Down’s syndrome, trisomy 21, is one of a number of conditions that may be screened
for using serum markers, as part of the quadruple test. Reduced serum α-fetoprotein
(AFP) is associated with pregnancies affected by Down’s syndrome. AFP is produced
by the fetal liver and yolk sac. Reduced levels of AFP are thought to be secondary
to the smaller size of fetuses affected by Down’s syndrome. Beta-human chorionic
Answers 107
tumorigenesis. Both BRCA genes are passed on via autosomal dominant inheritance.
This means that only one defective copy of the gene is required for the gene to be
expressed. An individual with a parent carrying the mutated BRCA1 gene has a one
in two chance of inheriting the gene themselves. See Figure 6.2 for diagrammatic
representation of autosomal inheritance.
Father Mother
Normal BRCA1 Defective copy
genes of BRCA1 gene
b b B b
Offspring B b b b B b b b
Defective copy Normal Defective copy Normal
of BRCA1 BRCA1 of BRCA1 BRCA1
gene genes gene genes
Families that carry either BRCA1 or BRCA2 mutations have a high incidence of breast
and ovarian cancers (particularly of early onset), with individuals with the defective
genes having an estimated 80% lifetime risk of breast cancer and up to a 40%
lifetime risk of ovarian cancer.
Connor JM. Medical Genetics for the MRCOG and Beyond. London: RCOG Press, 2005.
National Cancer Institute at the National Institutes of Health. Fact Sheet: BRCA1 and BRCA2: Cancer Risk
and Genetic Testing. Bethesda: National Cancer Institute, 2009. http://www.cancer.gov
13. A
Alpha-thalassaemia with deletion of 4α-globin genes
Alpha-thalassaemia is an autosomal recessive condition associated with deletions
in genes responsible for the production of α-globin chains. This couple both
have α-thalassaemia trait, which means they each have either 2α-globin gene
deletions on the same chromosomes or two chromosomes each with an α-globin
gene deletion. Severity of α-thalassaemia is largely dependent on the number
of α-globin genes affected. Individuals with the α-thalassaemia trait are usually
minimally affected other than a mild anaemia. However in fetuses with deletions in
all of the 4α-globin chains there is a complete absence of α-globin production. In
early fetal life embryonic globin and gamma chains form functional units. At later
gestations there is formation of haemoglobin Bart’s (excess gamma chains which
form tetramers) which has a high affinity for oxygen and therefore little oxygen
delivery capacity. Hydrops fetalis is seen in fetuses with this profound absence of
α-globin. Previously thought to be incompatible with life some fetuses may now
survive with intrauterine transfusion.
Chapter 7
Physiology
Questions: MCQs
Answer each stem ‘True’ or ‘False’.
1. Methods of contraception:
A The levonorgestrel intrauterine system works by preventing sperm fertilising
an egg
B Male sterilisation involves cutting the vas deferens
C The contraceptive implant works by preventing ovulation
D The contraceptive patch is suitable for those with a body mass index >40
E The combined oral contraceptive pill is contraindicated in migraine with aura
2. Regarding spermatogenesis:
A Each spermatid contains 23 chromosomes
B Spermatogenesis is completed in 40 days
C Each spermatogonium develops into a single spermatid
D Spermatids mature in the Leydig cells
E Spermatogenesis occurs through mitotic division
8. Concerning oxytocin:
A It is a nonapeptide
B Oxytocin agonists are used to manage threatened preterm labour
C It can be given to increase uterine tone post delivery
D Administration can cause hyponatraemia
E It is made in the anterior pituitary gland
9. Ergometrine:
A Administration can cause hypertension
B Can be used to augment labour
C Can be used in the third stage of labour
D Is a serotonin agonist
E Is a constituent of the drug oxytocin
D Contains dipalmitoylphosphatidylcholine
E Reduces pulmonary surface tension
15. Urine:
A pH is relatively acidic compared to plasma
B Composition changes with diet
C Usually contains a trace of glucose
D Creatinine levels are lower than in plasma
E In normal circumstances it is protein free
114 Chapter 7 Physiology
Questions: SBAs
17. A 23-year-old woman develops a fever and has offensive vaginal discharge and
abdominal pain. You are concerned that she is septic and wish to administer
intravenous antibiotics. Prior to administration you wish to calculate her
estimated glomerular filtration rate (eGFR) in order to dose her antibiotic therapy
appropriately.
Which of the following factors is included when calculating eGFR?
A Creatinine
B Diabetic status
C Height
D Medication
E Weight
18. A 25-year-old primiparous woman attends antenatal clinic for a routine check at
28 weeks’ gestation. Her urine dipstick shows glucose 2+. On questioning, she has
just eaten a doughnut.
Which of the following describes the sequential handling of glucose by
the kidney?
A Filtered, reabsorbed and secreted
B Filtered, reabsorbed and not secreted
C Filtered, secreted, but not reabsorbed
D Filtered and neither secreted or reabsorbed
E Unfiltered, secreted
19. A 37-year-old woman attends her general practitioner for contraceptive advice.
She is a smoker of 10 cigarettes a day and has had two children. She is keen to try
the progesterone-only pill and asks you how it works.
Which is the most appropriate answer?
A Creates a hostile environment for fertilisation to occur
Questions: SBAs 115
20. A 72-year-old woman undergoes a total abdominal hysterectomy. She has chronic
obstructive pulmonary disease. Postoperatively, she is difficult to extubate and has
a prolonged stay on the intensive care unit.
Which of the following is the most important direct stimulus to respiration?
A Decreased arterial pH
B Decreased arterial pO2
C Decreased arterial pCO2
D Increased H+ concentration of the cerebrospinal fluid (CSF)
E Increased pCO2 of the CSF
23. With regard to the cardiac cycle what is the definition of stroke volume?
A Stroke volume = cardiac output / body surface area
B Stroke volume = end diastolic volume – end systolic volume
C Stroke volume = end systolic volume – end diastolic volume
D Stroke volume = end systolic volume + end diastolic volume
E Stroke volume = end diastolic volume + end systolic volume
116 Chapter 7 Physiology
24. A 2-week-old neonate is admitted to hospital with failure to thrive, tachypnoea and
difficulty feeding. He is thought to have a circulatory defect.
Administration of prostaglandin antagonists soon after birth can be used to
therapeutically close which patent structure of fetal origin?
A Ductus arteriosus
B Ductus venosus
C Foramen ovale
D Fossa ovalis
E Ligamentum venosum
26. A 22-year-old woman is breastfeeding an hour after delivery. During lactation the
'let-down' reflex is stimulated by the action of which hormone?
A Human placental lactogen
B Oestrogen
C Oxytocin
D Prolactin
E Progesterone
27. A 27-year-old woman is being treated for primary infertility. A pelvic ultrasound
shows multiple small ovarian follicles present in both ovaries. She is having
ultrasound tracking of her ovaries as she has an irregular cycle.
What is the approximate size of the dominant ovarian follicle at the time of
ovulation?
A 1–2 mm
B 5 mm
C 20 mm
D 30–40 mm
E 50 mm
A Decreased haemoglobin
B Decreased 2,3-diphosphoglycerate
C Increased acidity
D Increased carbon dioxide
E Increased temperature
29. Which of the following substances is unable to bind with fetal haemoglobin?
A 2,3-diphosphoglycerate
B Carbon dioxide
C Carbon monoxide
D Nitrous oxide
E Oxygen
Answers
1. A False
B True
C True
D False
E True
The levonorgestrel intrauterine system is a plastic device containing progesterone,
which works by releasing hormone slowly into the system. The progesterone works
to thin the endometrium and so preventing implantation. It also thickens the
cervical mucus. Male sterilisation is a permanent form of contraception caused by
cutting, sealing or tying the vas deferens, which carries the sperm from testicles to
the penis. It is very effective, with less than a 1% failure rate.
The contraceptive implant is placed into the non-dominant upper arm. It releases
progesterone and causes the usual progesterone effects as well as preventing
ovulation. It can be left in situ for 3 years, but can be taken out sooner with a
potential return to fertility immediately. The contraceptive patch is not suitable
for those women with a large body mass index or smokers. The combined oral
contraceptive pill is contraindicated for use as a contraceptive in patients with
migraine with aura.
National Institute for Health and Clinical Excellence. Long-acting reversible contraception. Clinical
Guideline CG30. London: NICE, 2005. http://guidance.nice.org.uk/CG30
2. A True
B False
C False
D False
E True
Spermatogenesis (Figure 7.1) refers to the process that produces mature sperm
(spermatozoa) from primitive germ cells (spermatogonia). Starting in adolescence
and continuing throughout male adulthood spermatogenesis takes around 70 days
to complete. During this time the spermatogonia found at the basal lamina of the
seminiferous tubules begin to mature, eventually becoming primary spermatocytes.
Both spermatogonia and primary spermatocytes contain a diploid number of
chromosomes, which is reduced to haploid number (23 chromosomes) as a result of
meiotic division. The primary spermatocyte divides by meiosis into two secondary
spermatocytes (first meiotic division), each of which then divide again (second meiotic
division) to form two spermatids each. These haploid spermatids then undergo a process
of maturation attached to the Sertoli cells, eventually becoming mature spermatozoa.
Answers 119
Meiosis 1
Meiosis 2
Spermatid (n)
Spermatozoa (n)
3. A False
B False
C True
D False
E True
Angiotensin-converting enzyme (ACE) is produced predominantly by the
endothelial cells of the lungs, but also in the kidneys. ACE catalyses the conversion
of angiotensin I to angiotensin II which is a vasoconstrictor and key regulator of
extracellular volume as part of the renin–angiotensin system. ACE is also known
to cause breakdown of the peptide bradykinin, a potent vasodilator. ACE may be
raised in a number of pathologies including primary biliary cirrhosis, sarcoidosis and
Gaucher’s disease.
ACE inhibitors such as ramipril and enalapril prevent angiotensin II formation and
induce a state of relative vasodilation.
4. A False
B True
C True
D True
E True
120 Chapter 7 Physiology
Adapted from: Appendix 2: Normal laboratory values in pregnancy/non-pregnancy. In: Handbook of Obstetric
Medicine, 4th edn. London: Informa Healthcare, 2010: 273–274.
6. A False
B True
C False
D False
E False
Answers 121
The third stage of labour is defined as the time from delivery of the baby to the
delivery of the placenta and membranes. It may be managed physiologically or more
commonly, actively. Physiological management involves delivery of the placenta by
maternal effort. No oxytocin or ergometrine is used.
Active management of the third stage, however involves clamping of the cord, the
use of uterotonics such as oxytocin and ergometrine, and delivery of the placenta by
controlled cord traction.
Side effects of oxytocin include nausea and vomiting. Rarer side effects include
arrhythmias, disseminated intravascular coagulation and water intoxication and
hyponatraemia. Ergometrine may also be associated with side effects such as nausea
and vomiting, arrhythmias, chest pain and palpitations. Active management of the
third stage is recommended to avoid postpartum haemorrhage in women at risk of
postpartum haemorrhage, such as grand multiparous women.
7. A False
B True
C False
D False
E True
The term ‘luteoplacental’ shift refers to the transition that occurs in early pregnancy
when the placenta takes over progesterone production from the ageing corpus
luteum. This shift occurs at around 7–8 weeks’ gestation. The corpus luteum secretes
17α-hydroxyprogesterone throughout the luteal phase of the menstrual cycle; should
fertilisation not occur the corpus luteum fails 14 days after ovulation, progesterone
levels significantly reduce and menstruation occurs. When fertilisation has occurred
human chorionic gonadotrophin produced by the syncytiotrophoblast stimulates the
corpus luteum to continue producing progesterone. At around 7–8 weeks’ gestation
the placenta becomes the main source of progesterone synthesis. The corpus
luteum begins to fail and eventually will become a corpus albicans. Failure of the
corpus luteum to maintain progesterone levels prior to the ‘shift’ is associated with
first trimester miscarriage. Progesterone support is required in assisted conception
pregnancies until the shift has occurred.
Csapo A. The luteo-placental shift, the guardian of pre-natal life. Postgrad Med J 1969;45(519):57–64.
8. A True
B False
C True
D True
E False
Oxytocin is a nonapeptide hormone which is made in the hypothalamus and released
from the posterior pituitary gland. Numbers of oxytocin receptors in uterine muscle
increase close to term, and increased release of oxytocin in labour is thought to aid
uterine muscle contraction.
122 Chapter 7 Physiology
Oxytocin is also involved in the ‘let-down’ reflex of milk ejection as part of lactation.
Synthetic forms of oxytocin, such as ‘syntocinon’, can be given to augment labour or
to prevent/manage postpartum haemorrhage by stimulating uterine contraction.
Oxytocin has a similar structure to that of vasopressin (antidiuretic hormone), and
therefore administration can be associated with hyponatraemia.
‘Atosiban’ is a tocolytic agent and is an oxytocin antagonist. It is used in cases of
threatened preterm labour.
9. A True
B False
C True
D True
E False
Ergometrine is an ergot alkaloid that is known to act as a serotonin, dopaminergic
and α-adrenergic agonist. Although its true mechanism of action is not fully
understood, ergometrine is known to aid both vasoconstriction and uterine
contraction thus making it a useful drug for the management of the third stage of
labour and the prevention postpartum haemorrhage.
Use of ergometrine is contraindicated in the first and second stage of labour.
Ergometrine is often given in combination with a synthetic oxytocin in the form of
‘syntometrine’. Known to cause vasoconstriction, ergometrine should be given with
caution to women with raised or borderline blood pressure and significant renal
disease. Administration in such cases may be associated with further increases in
blood pressure, and hence its use is contraindicated in women with pre-eclampsia.
10. A True
B False
C False
D True
E True
In pregnancy, the normal electrocardiogram (ECG) is slightly different from that
of the non-pregnant state, with changes reflecting the altered physiology of
pregnancy. As pregnancy is associated with increased blood volume, increased
stroke volume and increased cardiac output there is associated hypertrophy of the
heart and enlargement of the left side of the heart. The gravid uterus also pushes the
diaphragm up, and therefore the heart is displaced forward and to the left.
The combination of these changes lead to left-axis deviation on the ECG. There may
also be T-wave inversion or flattening in Lead III and the presence of Q waves in both
leads aVF and III.
Ciliberto CF, Marx GF. Physiological changes associated with pregnancy. Update Anaesthesia 1998; 9:1-3.
Answers 123
11. A True
B False
C True
D False
E False
Lactation suppression may be instigated by interruption of the normal balance of
lactation promoters and inhibitors. Prolactin is the main promoter of lactation and
is produced by the pituitary gland. It is inhibited by dopamine agonists such as
cabergoline and bromocriptine. These drugs can be given to suppress lactation in
HIV positive women or those who are not breastfeeding because they have had a
stillbirth.
Dopamine antagonists unsurprisingly have the opposite effect and drugs such
as metoclopramide and domperidone are sometimes used to increase milk
production.
With regards to postnatal contraception the progesterone-only contraceptive pill is
often the contraceptive of choice in breastfeeding women in the postpartum period.
It does not interfere with lactation. The combined oral contraceptive pill, however, is
relatively contraindicated due to its oestrogen content and concerns with regards to
it reducing the volume and quality of breast milk.
12. A True
B False
C False
D True
E True
Pulmonary surfactant is a naturally occurring substance produced
by type II pneumocytes. It predominantly consists of lipids [such as
dipalmitoylphosphatidylcholine (DPPC)] which are linked with a series of surfactant
proteins (A, B, C and D) and organised into hydrophobic and hydrophilic complexes.
Pulmonary surfactant increases lung compliance and reduces pulmonary surface
tension which helps prevent atelectasis.
Surfactant production begins in the fetus relatively late in pregnancy and
is therefore suboptimal in infants born prematurely. Respiratory distress
syndrome is a major cause of mortality and morbidity in premature infants due
to lack of surfactant and lung immaturity. The administration of intramuscular
glucocorticoids such as dexamethasone and betamethasone is associated with
increased fetal surfactant production and enhanced lung maturity and therefore
has benefit when there is risk of delivery before 34 weeks’ gestation.
124 Chapter 7 Physiology
13. A False
B True
C False
D True
E False
Expansion of the chest cavity occurs as a result of contraction of the intrathoracic
muscles which are innervated from the T1–T11 nerves. There is also influence
from the diaphragm which is innervated by the phrenic nerve, C3–C5. There are
two important controls to respiration, the central chemoreceptors (medulla)
and peripheral chemoreceptors (aortic arch and carotid body). The aortic arch
receptors are innervated by the vagus nerve and the carotid body receptors by
the glossopharyngeal nerve. The carotid body chemoreceptors are the only ones
sensitive to changes in the partial pressure of oxygen. Both peripheral and central
chemoreceptors are sensitive to changes in both pCO2 and pH. If there is an increase
in the level of pCO2 detected, then there is an associated increase in ventilation to
reduce the pH.
14. A True
B True
C True
D False
E False
An adult liver weighs approximately 1 kg and is composed of lobules. Each lobule
surrounds a central vein which then drains into a hepatic vein. Kupffer cells are
phagocytic and line the sinusoids. Bilirubin is a breakdown product of haemoglobin
and is then secreted by the liver.
The synthesis of lipoproteins occurs in the liver, but the main lipoprotein to be
manufactured is VLDL. Plasma proteins are derived from the liver and nearly
all albumin and fibrinogen are synthesised here. The neonatal liver weighs
approximately 150 g and is immature at birth. Physiological jaundice occurs as
a result of the neonatal liver’s failure to conjugate the bilirubin. High levels of
unconjugated bilirubin mean that it cannot be completely bound to albumin and
may cross the blood-brain barrier, causing kernicterus.
15. A True
B True
C False
D False
E True
Table 7.2 summarises the properties of urine.
Answers 125
16. E Thrombocytopaenia
Disseminated intravascular coagulopathy (DIC) is a condition, where there is
generalised and widespread pathological activation of the clotting system. There
is clotting within the microvasculature which causes consumption of coagulation
products. Pathological changes include inflammatory activation, suppression of
anticoagulation and inhibition of fibrinolysis. The obstruction of the microvascular
vessels can cause disruption of blood flow to major organs, potentially leading to
multiorgan failure.
DIC usually occurs as a result of activation of the intrinsic coagulation pathway.
There are usually increased levels of soluble fibrin. Diagnosis is by blood tests which
usually reveal:
• Thrombocytopaenia
• Prolonged activated partial thromboplastin time
• Low fibrinogen
• Increased fibrinogen degradation products
Treatment is via reversal of the underlying cause. Fresh frozen plasma may be given
as well as platelets depending on the degree of thrombocytopaenia.
17. A Creatinine
Estimated glomerular filtration rate is used as a marker of renal function and used
in clinical practice, e.g. for calculations of renal function in the use of nephrotoxic
drugs. It is often calculated using the modification of diet in renal disease (MDRD)
equation which takes into account the age, creatinine levels, gender and ethnic
group. Weight, height, comorbidities and medication are not used in this formula.
It must be remembered that estimated glomerular filtration rate (eGFR) is still
an estimate and may be inaccurate in certain circumstances, e.g. malnourished
patients and amputees. It should not be used in children or pregnant women. For
Afro-Caribbean patients, the eGFR may be 21% higher than estimated. Normal GFR
is > 90 mL/min/1.73 m2.
126 Chapter 7 Physiology
20. D
Increased H+ concentration of the
cerebrospinal fluid
The main stimulus to the respiratory centre comes from the chemoreceptors.
These are central and peripheral. The central chemoreceptors are found on the
surface of the upper medulla. Peripheral chemoreceptors are around the aortic
arch, innervated by the vagus nerve, and in the carotid body, innervated by
the glossopharyngeal nerve. The central chemoreceptors are only sensitive to
changes in the pH. The carotid body receptors are sensitive to changes in pO2.
Both the carod body and aortic arch receptors are sensitive to changes in pCO2
and pH. Variations in CO2 are altered via a change in ventilation. A rise in CO2
leads to an increase in ventilation and hypoxia increases the respiratory centre
sensitivity to CO2. The response to hypoxia is less marked than the response to
CO2. The response to respiration as a result of acidosis is reduced because of the
production of deoxygenated haemoglobin which acts as a buffer.
FEV1, forced expiratory volume in 1 second; PEFR, peak expiratory flow rate.
23. B
Stroke volume = end diastolic volume – end
systolic volume
The cardiac cycle is the repeated action of contraction and relaxation that leads to
the pumping of blood from the heart and maintenance of circulation. Myocardial
cells contract during electrical excitation and relax during repolarisation. During
diastole the heart chambers relax and fill with blood. During systole, there is
contraction of the ventricles and ejection of blood into the circulation. The atria
contract together, with contraction of the ventricles occurring 0.1–0.2 seconds
later.
Concerning the left side of the heart: at the beginning of ventricular systole, the
mitral valve is open and the pressure in the left atrium is greater than that in the
128 Chapter 7 Physiology
ventricle. As the pressure in the left atrium builds up, the mitral valve closes. Stroke
volume is the calculated by subtracting the end systolic volume from the end
diastolic volume. This is actually around 60–70% of blood left in the ventricles at
the end of diastole. Stroke volume usually refers to the left ventricle, although it can
be applied to both. Both ventricles have an equivalent stroke volume, which in the
average sized adult is approximately 70 mL.
25. E Vasopressin
Nephrons are the functional unit of the kidney and are responsible for the filtration
of blood, excretion of waste products and the regulation of water balance. The
collecting duct is the terminal part of the nephron and receives filtrate that has
already passed through the glomerulus (the main functional filtration unit), the loop
of Henle and the proximal and distal convoluted tubules. By the time the filtrate
reaches the collecting duct it has already undergone a process of reabsorption of
substances such as sodium chloride, water, bicarbonate, potassium and calcium.
At the collecting duct vasopressin, also known as antidiuretic hormone, increases
permeability to water allowing for water molecules to be reabsorbed. Vasopressin
enables the production of concentrated urine by acting on the aquaporins (water
channels) of the collecting duct, allowing them to facilitate the passive reabsorption
of water (Figure 7.2).
Chapter 38: Renal Function and Micturition. In: Barrett KE, Barman SM, Boitano S, Brooks H. Ganong’s
Review of Medical Physiology, 23rd edn. New York: McGraw-Hill, 2010.
Answers 129
Action of Action of
parathyroid hormone aldosterone
Key
Bowmans
capsule H2O
Glomerulus Solutes
Filtrate
Cortex Proximal Distal
convoluted convoluted
tubule tubule
Action of
Descending vasopressin
Outer limb (antidiuretic
medulla hormone)
Ascending
limb
Inner Collecting
medulla tubule
26. C Oxytocin
The ‘let-down reflex’, also known as the milk ejection reflex, describes the release of
breast milk following the stimulus of suckling. The reflex is controlled by the action
of the hormone oxytocin which is released from the hypothalamus in response
to suckling, and causes contraction of the myoepithelial cells of the milk ducts
subsequently leading to milk ejection. Conditioning of this reflex naturally occurs to
the extent that milk ejection may occur in lactating women in response to stimuli
such as the sound of crying babies. Actual production of milk is largely under the
control of prolactin which is released from the anterior pituitary gland in increasing
amounts from early pregnancy.
27. C 20 mm
The dominant ovarian follicle grows considerably throughout folliculogenesis and by
the time of ovulation has reached approximately 20 mm in size. It reaches the surface
of the ovary and its release is due to necrobiosis of the overlying tissue. The rise in basal
body temperature is thought to be due to the thermogenic effect of progesterone on
the brain. The actual process of follicular rupture takes a few minutes. Mittelschmerz
is the midcycle lower abdominal pain experienced by almost 1 in 4 women. This is
thought to be caused by the release of follicular fluid leading to peritoneal irritation.
130 Chapter 7 Physiology
– decreased
2,3-diphosphoglycerate
29. A 2, 3-diphosphoglycerate
The oxygen dissociation curve for fetal haemoglobin (HbF) is a sigmoid shape. HbF
consists of two α chains and two γ chains. HbF has a higher affinity for oxygen and
there is therefore a left shift in the fetal oxygen dissociation curve. The reason for this
shift is the reduced binding of 2,3-diphosphoglyceric acid (2,3-DPG). 2,3-DPG has
a higher affinity for the β chains in the adult haemoglobin (HbA). This difference in
binding capacity between HbA and HbF ensures that HbF has a greater affinity for
oxygen than HbA. The P50 is defined as the partial pressure of oxygen at which the
oxygen-carrying protein is 50% saturated and this is lower in HbF due to the reduced
sensitivity of 2,3-DPG (Figure 7.4).
Answers 131
Adult haemoglobin
Oxygen saturation (%)
30. E
Vital capacity = inspiratory capacity + expiratory
reserve volume
Vital capacity describes the maximum volume of air that a person can exhale after
maximum inspiration. It is therefore the combination of inspiratory capacity and the
expiratory reserve volume. The inspiratory capacity is the combination of inspiratory
reserve volume plus the tidal volume and is approximately 2.4 L in a female adult.
The expiratory reserve volume is determined by the functional residual volume
minus the residual volume. Vital capacity may be measured by spirometry and forms
one element of a basic lung function test.
Chapter 8
Biophysics
Questions: MCQs
Answer each stem ‘True’ or ‘False’.
1. Ultrasound causes:
A Cavitation
B Heating
C Microstreaming
D Decreased velocity of blood flow
E Ionisation
3. Concerning electrosurgery:
A Bipolar diathermy can be used to cut tissue
B Monopolar diathermy necessitates the use of a return electrode
C Diathermy uses low-frequency electrical currents
D Desiccation of tissue can be achieved using both mono- and bipolar diathermy
E Direct coupling is achieved by adhering to strict safety protocols
6. Ultrasound:
A Has no known adverse effects on tissue
B Can have thermal effects on tissue
C Can cause streaming
D Can cause fulguration
E Safety protocols necessitate the use of thermal indices
Questions: SBAs 135
Questions: SBAs
For each question, select the single best answer from the five options listed.
7. Which of the following describes the mode used in creating standard grey scale
ultrasound images?
A A-mode
B B-mode
C Doppler mode
D M-mode
E None of above
11. The standard chest X-ray is equivalent to what duration of natural background
radiation:
A 2–3 days
B 10 days
C 2 months
D 18 months
E 5 years
12. At what crown–rump length would you first expect to see a fetal heart beat using
transvaginal ultrasonography?
136 Chapter 8 Biophysics
A > 2 mm
B > 3 mm
C > 4 mm
D > 5 mm
E > 6 mm
13. A 68-year-old woman developed left-sided chest pain a day after she has had
total abdominal hysterectomy and bilateral-salpingo-oophorectomy. A 12-lead
electrocardiogram is performed and is suggestive of an anterior ST elevation
myocardial infarction.
Which of the following leads would be most likely to show ST elevation in this
patient?
A I, aVL, V5–V6
B I, II and III
C II, III and aVF
D V1–V4
E All of the above
Answers
1. A True
B True
C True
D False
E False
Ultrasonography uses high frequency sound waves to create images that are
widely used in many area of medical practice. Although generally considered a
safe modality of imaging it can cause a number of tissue effects. Ultrasound causes
heating of the surrounding tissues, the extent of which is dependant on the tissue
type, the distance between the transducer and the tissue and the intensity of the
ultrasound used. Cavitation describes the formation of gas cavities within tissue
secondary to ultrasound. Although cavitation is not thought to occur in diagnostic
ultrasonography, it can be practically applied in lithotripsy. Microstreaming is
the generation of fluid circulation within tissue, which can be either intra- or
extracellular. Ionisation does not occur as a result of the usage of ultrasound.
2. A True
B True
C False
D False
E True
Soft markers are more common in a fetus with chromosomal abnormalities. However,
the presence of these markers alone is not sufficient to provide a definitive diagnosis
as they often spontaneously resolve. Choroid plexus cysts may be seen in a fetus
with trisomy 18; however, when seen in an otherwise normal fetus they are of
questionable significance. Echogenic bowel describes bowel that appears bright
on ultrasound and can indicate chromosomal abnormalities, bowel obstruction
and cystic fibrosis. It always requires further investigation. Exomphalos is persistent
protrusion of the bowel through the abdominal wall at the base of the umbilicus. This
may be normal before 10 weeks of gestation. The ongoing presence of exomphalos
may be indicative of chromosomal abnormalities or other organ malformation.
Fetal hydrops refers to the accumulation of serous fluid in fetal tissue and may be
associated with diagnoses such as parvovirus infection and anaemia. Mild renal pelvic
dilatation is associated with only a small risk of chromosomal abnormalities.
3. A False
B True
C False
D True
E False
138 Chapter 8 Biophysics
which is used to inject a radio-opaque contrast agent into the uterus and through
the fallopian tubes. X-ray images are obtained to show the passage of the contrast
agent into the uterus and, when there is tubal patency, to visualise the bilateral spill
out of each fallopian tube. The procedure must be performed during the follicular
phase of the menstrual cycle and within 10 days of menstruation to prevent
radiation exposure to an early embryo. An HSG should not be performed when there
is co-existing, untreated pelvic infection.
StratOG.net. Epidemiology, ethical and legal issues of subfertility. London: StratOG, 2012. www.rcog.org.
uk/stratog
6. A False
B True
C True
D False
E True
Overall, ultrasound is considered a safe imaging modality. Nevertheless its usage
does require monitoring to ensure that there are no adverse effects related to
its use. The main concerns regarding the usage of ultrasound relate to thermal
effects related to the heating of local tissue. In order to reduce the potential impact
of exposing an embryo or fetus to the thermal effects to ultrasound, exposure
should be kept to a minimum. Particular caution should be applied when using a
transvaginal probe in early pregnancy. Thermal indices are used, as a measure of
tissue heating effects and safety protocols necessitate the use of minimising the
thermal index (to < 1) and keeping scanning time as short as possible to prevent
tissue heating. Fulguration is the destruction of tissue using electrosurgery.
Ambramowicz JS, Kossoff G, Marsal K, Ter Haar G. Safety Statement, 2000 (reconfirmed 2003). Ultrasound
Obstet Gynecol 2003; 21:100.
Salvesen K, Lees C, Ambramowicz J, et al. ISUOG statement on the safe use of Doppler in the 11 to
13+6-week fetal ultrasound examination. Ultrasound Obstet Gynecol, 2011; 37:628.
7. B B-mode
A-mode is the simplest form of ultrasound and is now rarely used. It creates wave
spikes as the ultrasound comes into contact with various tissues. The distance
between the spikes can be measured. The A in A-mode refers to the amplitude of the
ultrasound used. B-mode, or brightness mode, is widely used in ultrasound to create
two-dimensional greyscale images obtained from a linear array of transducers,
which simultaneously scan a tissue plane. M-mode incorporates movement with
successive A- or B-mode images. Doppler mode is used to assess movement and
therefore is the mode used for looking at blood flow. There are various different
types of Doppler used including pulsed wave, continuous and colour.
10. E X-ray
High energy forms of radiation capable of separating an electron from an atom are
described as ‘ionising’. Forms of ionising radiation can have therapeutic properties,
but require close regulation to prevent excessive exposure. Table 8.1 lists sources of
ionising and non-ionising radiation.
Modality Time period for effective dose from natural background radiation
Chest X-ray 7–10 days
CT of abdomen 3 years
Lumbar spine X-ray 6 months
Intravenous urogram 1 year
12. A > 2 mm
Fetal heart action should be evident when the crown–rump length (CRL) is >2 mm.
However, in 5–10% of embryos there will be no fetal heart action visible until
> 4 mm. When using ultrasound to diagnose the viability of a pregnancy, a CRL of
≥7 mm and absence of fetal heart action suggests a non-viable pregnancy. In these
cases a further scan may be indicated after an interval of at least 1 week.
Royal College of Obstetricians and Gynaecologists. The Management of Early Pregnancy Loss. Green-top
Guideline 25. London: RCOG, 2006.
Royal College of Obstetricians and Gynaecologists. Addendum to GTG No 25. The Management of Early
Pregnancy Loss, 2011. www.rcog.org.uk
13. D V1–V4
Bearing in mind that varying electrode placement allows the electrocardiogram
to create a pictorial representation of electrical activity in the heart it is possible
to localise pathological changes in the heart’s conduction pathways. Leads V1–V4
detect electrical activity in the anterior part of the heart along the horizontal
plane. Therefore, when there is a considerable change in the heart conduction
pathways as a consequence of an anterior myocardial infarction we may expect to
see ST wave elevation in these leads. An inferior ST elevation myocardial infarction
(STEMI) would be represented as ST wave elevation in leads II, III and aVF. Electrical
activity in the lateral aspect of the heart is monitored by V5 and V6, as well by as
leads I and aVL. Thus, a lateral STEMI is likely to be seen as ST elevation in leads I,
aVL and V5 to V6.
14. B Lymphoedema
Radiotherapy is a form of ionising radiation that is widely used in the treatment
of cancers, but may also be used to for a variety of non-malignant conditions.
Radiotherapy is effective in damaging the cellular DNA and thus causing cellular
death. The ionising radiation is targeted at localised areas to avoid generalised
exposure to its effects. Like any intervention, radiotherapy has side effects which can
be classified to acute or late (Table 8.3). Lymphoedema is one such late side effect
and typically occurs following pelvic and breast radiotherapy.
StratOG.net, Principles of Radiotherapy. London: stratOG, 2010. www.rcog.org.uk/stratog
142 Chapter 8 Biophysics
15. C
It is the opposition to the passage of sound
waves and is a function of density and elasticity
Acoustic impedance is a term used in the description of ultrasound behaviour
within a tissue. It represents the opposition to the passage of sound waves and is a
function of density and elasticity. Refraction is the change in direction of the wave
as a result in change of speed. Diffraction describes the bending of waves during
its passage as a result of interaction with obstacles. Reflected waves from a moving
object undergoing a frequency shift is the Doppler effect. Colour Doppler provides
an estimate of mean velocity of flow within a vessel.
Chapter 9
Clinical management
Questions: MCQs
Answer each stem ‘True’ or ‘False’.
6. The following laboratory tests should be carried out on all women who present
with heavy menstrual bleeding:
A Hormone profile
B Serum ferritin
C Thyroid function test
D Coagulation function
E Full blood count
Questions: SBAs
For each question, select the single best answer from the five options listed.
12. A 26-year-old woman attends the emergency department feeling unwell and
complaining of lower abdominal pain. On examination she has a temperature
of 39 °C and a pulse rate of 110 beats per minute. She has lower abdominal
tenderness with guarding and cervical excitation. A speculum examination
reveals profuse discharge.
What is the most appropriate management?
A Admit for intravenous antibiotics and supportive care
B Book for a diagnostic laparoscopy
C Organise a pelvic ultrasound scan
D Refer for a surgical review
E Refer to a sexual health clinic for screening and partner contact tracing
13. A 27-year-old female teacher, who is 14 weeks pregnant, presents to her general
practitioner as she is concerned because one of her students was sent home today
with chickenpox. Her varicella zoster virus IgG antibody is positive.
What is the correct advice to give her?
A Chickenpox is not contagious once the rash appears so she need not worry
B She is immune to chickenpox and no further action needs to be taken
C She should have be referred to fetal medicine unit for a scan to exclude
abnormality
D She should not attend the hospital as she may infect other pregnant women
E She should receive varicella zoster immune globulin within the next 24 hours
for it to be effective
14. A 28-year-old patient attends out patient clinic with primary subfertility. Her
partner's semen analysis and her hysterosalpingogram are normal. Her follicle-
stimulating hormone is 2.3 IU/mL, luteinising hormone is 6.8 IU/mL, and her day
21 progesterone is 19 ng/mL.
What is the most likely cause for her subfertility?
A Asherman’s syndrome
B Endometriosis
C Hypogonadotrophic hypogonadism
D Premature menopause
E Polycystic ovaries
A Concealed abruption
B Placenta praevia
C Premature labour
D Revealed abruption
E Vasa praevia
16. A 40-year-old woman complains of heavy regular periods for 5 years. Ultrasound
scan has revealed no abnormality. Her family is complete.
What is the most appropriate first line treatment for this patient?
A Combined contraceptive pill
B Laparoscopic assisted vaginal hysterectomy
C Levonorgestrel-releasing intrauterine system (IUS)
D Norethisterone tablet 5 mg three times daily from day 5 to 26
E Tranexamic acid
18. A 22-year-old woman with a past history of Chlamydia attends the emergency
department complaining of severe abdominal pain. She has mild vaginal bleeding.
Her pulse rate is 120 beats per minute, with a blood pressure of 60/40 mmHg and
she has a distended tender abdomen.
What is the most likely diagnosis?
A Acute appendicitis
B Complete miscarriage
C Ruptured ectopic pregnancy
D Threatened miscarriage
E Urinary tract infection
19. You are asked to review a 20-year-old woman in the emergency department.
She has a positive pregnancy test, and is unsure of her last menstrual period.
On examination, her pulse is 70 beats per minute and her blood pressure is
110/70 mmHg. Her abdomen is soft and non-tender. Speculum examination
reveals a closed cervix and mild bleeding.
What is the most appropriate plan of management?
A Admit the patient and arrange an evacuation of retained products of conception
B Admit the patient for a laparoscopy as an ectopic pregnancy cannot be
excluded
Questions: SBAs 147
20. A 30-year-old patient, who is hypertensive and obese with a body mass index of 38,
requests contraception. She has had two previous caesarean sections.
What is the most effective and safest form of contraception for her?
A Laparoscopic sterilisation
B Combined oral contraceptive pill
C Subdermal implant
D Barrier contraception
E Intrauterine device
21. A 44-year-old is 28 weeks pregnant with ovum donation. She presents with
headache and reports seeing ‘flashing lights’. Her blood pressure is 172/112 mmHg
and her pulse rate is 78 beats per minute. Urine dipstick shows protein +++,
leucocytes trace, nitrites negative, blood trace.
Which is the most appropriate immediate management for this patient?
A Request an urgent scan for fetal growth
B Administer antihypertensives to lower her blood pressure
C Administer ramipril
D Avoid steroid injections as it will worsen her blood pressure
E Immediate delivery of the baby by category one caesarean section
22. The risk of malignancy index (RMI) is used to score the risk of ovarian cancer in
women.
Which of the following is correct with regards to the basis of its calculation?
A Classification of post menopausal is a woman who has had no periods for
2 years or over age of 51 years
B Premenopausal status is scored as 3
C Serum CA-125 levels are measured on a scale of 1 to 10
D Ultrasound scan must show a cyst of at least 10 cm in size
E Ultrasound score × menopausal status × CA-125
23. A 27-year-old woman attends the antenatal clinic at 14 weeks’ gestation in her
third pregnancy. She had a deep vein thrombosis, when she broke her leg during
a skiing trip at age 20 years. Her thrombophilia screen outside of pregnancy was
negative. She has no family history of venous thromboembolism.
Which of the following is the most appropriate action?
A Aspirin 150 mg from conception to 36 weeks’ gestation
B Low-molecular weight heparin therapy immediately
C Low-molecular weight heparin therapy from 24 weeks’ gestation until onset of
labour
148 Chapter 9 Clinical management
Answers
1. A False
B True
C False
D False
E True
Acute pelvic inflammatory disease (PID) lacks definitive clinical diagnostic criteria
but certain clinical features are highly suggestive of PID and treatment should start
without delay. Women with PID may present with:
• Lower abdominal pain
• Abnormal discharge
• Pain during intercourse
• Pyrexia
• Cervical motion and adnexal tenderness on bimanual examination.
Differential diagnosis must always include ectopic pregnancy, appendicitis, an
ovarian cyst accident, urinary tract infection, and gastrointestinal disorders.
Royal College of Obstetricians and Gynaecologists. Management of Acute Pelvic Inflammatory Disease.
Green-top Guideline 32. London: RCOG, 2008.
2. A False
B False
C False
D True
E False
Gonorrhoea is the second most common sexually transmitted bacterial infection in
the United Kingdom. It may sometimes be asymptomatic, but if left untreated it can
cause subfertility. Women with Gonorrhoea may present with abnormal discharge,
lower abdominal pain or dysuria. Testing should be with an endocervical specimen;
however, an additional sample from the urethra increases diagnostic yield when
testing by nucleic acid amplification test is not available. A pregnancy test should be
performed in all women who attend with lower abdominal pain or are suspected to
have pelvic inflammatory disease.
Royal College of Obstetricians and Gynaecologists. Management of Acute Pelvic Inflammatory Disease.
Green-top Guideline 32. London: RCOG, 2008.
3. A True
B False
C False
150 Chapter 9 Clinical management
D False
E False
Pelvic inflammatory disease (PID) is rarely seen with intrauterine pregnancy and
hence diagnosis of PID should be made with caution when looking for differential
diagnosis in pregnancy. All drugs used in pregnancy for any reason should be looked
at from risk benefit ratio and if benefits outweigh risks, they can be used. Treated or
untreated, PID does increase the risk of subfertility. Therefore, it is essential that even
if there is no robust evidence of PID on tests performed, if symptomatic, treatment
should be offered.
Royal College of Obstetricians and Gynaecologists. Management of Acute Pelvic Inflammatory Disease.
Green-top Guideline 32. London: RCOG, 2008.
4. A False
B False
C True
D False
E True
Abstinence of 2–3 days prior to performing a semen analysis is considered to be
ideal, as shorter abstinence may result in production difficulties. Longer abstinence
usually results in collection of dead sperm and debris in larger proportions. The
sample once produced should reach the laboratory, ideally, within 45–60 minutes
to assess the motility accurately. Normal condoms contain spermicides, so sperm
should only be collected either directly in the aseptic pot or into non-spermicidal
condoms.
National Institute for Health and Clinical Excellence. Fertility Assessment and Management for People
with Fertility Problems. Clinical Guideline CG11. London: NICE, 2004.
5. A False
B True
C False
D False
E False
Menorrhagia refers to heavy menstrual bleeding. Blood loss may be such that it
affects many aspects of a woman’s life, including her physical health and overall
quality of life.
A full blood count should be performed at presentation. If uterine structural
abnormalities such as fibroids are suspected, then ultrasound is a first line diagnostic
tool. A biopsy of the lining of the womb may be indicated in women above 45 years
old or those who present with persistent intermenstrual bleeding. Pharmaceutical
management, if appropriate, should be considered. Initial management includes
the insertion of a levonorgestrel-releasing intrauterine system (IUS) as a first choice,
Answers 151
with other options including tranexamic acid or the combined oral contraceptive.
Norethisterone or long-acting injected progestogens may also be considered.
Other treatments for heavy menstrual bleeding, other than hysterectomy, include
endometrial ablation, and in the presence of fibroids include myomectomy and
uterine artery embolisation.
National Institute for Health and Clinical Excellence. Heavy Menstrual Bleeding. Clinical Guideline CG44.
London: NICE, 2007.
6. A False
B False
C False
D False
E True
Women with heavy menstrual bleeding require a full blood count at their first
presentation. Thyroid function tests should only be performed if the signs and
symptoms of thyroid disease are present. A coagulation screen function should
not be performed, unless the history is suggestive of a coagulation abnormality.
A hormonal profile is not indicated. An assessment of serum ferritin is not usually
required.
National Institute for Health and Clinical Excellence. Heavy Menstrual Bleeding. Clinical Guideline CG44.
London: NICE, 2007.
7. A False
B False
C False
D False
E True
Malaria can be difficult to diagnose and may present as a flu-like illness. Pregnant
women with parasitaemia of 2% or more are at risk of developing severe malaria
which can manifest with respiratory distress, impaired consciousness or pulmonary
oedema. Laboratory investigation may reveal severe anaemia, thrombocytopaenia,
hypoglycaemia and impaired renal function.
Malaria in pregnancy requires microscopic diagnosis. The current gold standard for
the detection of malaria is the preparation of thick and thin blood films. Although
less sensitive, rapid detection techniques can be used, but they can miss the low
levels of parasitaemia that may be present in pregnant women, and they are less
able to detect the presence of Plasmodium vivax. In a febrile patient, three negative
malaria smears 12–24 hours apart are needed to exclude diagnosis of malaria.
Pregnant women with malaria should be admitted to hospital for treatment.
Choloroquine is used for treatment of P. vivax, P. ovale or P. malariae. All newborns of
mothers who have had malaria in pregnancy should be screened as there is a risk of
vertical transmission.
152 Chapter 9 Clinical management
Royal College of Obstetricians and Gynaecologists. The Diagnosis and Treatment of Malaria in Pregnancy.
Green-top Guideline 54B. London: RCOG, 2010.
8. A True
B True
C False
D False
E False
Women with HIV in pregnancy should be advised to take antiretroviral therapy and
this should be continued throughout labour. They should also be tested for hepatitis
C, varicella zoster, measles and toxoplasma.
Women with a viral load of <50 copies/mL can opt for a vaginal delivery. In case of
prolonged pregnancy in these women, a membrane sweep may be performed and
prostaglandins may be used.
In order to reduce the chance of vertical transmission, membranes should be kept
intact for as long as possible and invasive procedures, such as fetal blood sampling
and fetal heart monitoring via a scalp electrode, should be avoided. If instrumental
delivery is required, forceps should be used in preference over performing a
ventouse delivery.
Royal College of Obstetricians and Gynaecologists. Management of HIV in Pregnancy. Green-top
Guideline 29. London: RCOG, 2010.
9. A False
B False
C False
D False
E False
At the time of writing, the caesarean section rate in the United Kingdom was
around 25%. A raised body mass index alone should not be an indicator for elective
caesarean section. An external cephalic version should be offered to women with
an uncomplicated singleton breech pregnancy at 36 weeks’ gestation, rather than
automatically recommending an elective caesarean section. Small for gestational
age babies do not require delivery by elective caesarean. The risk of hysterectomy,
due to a postpartum haemorrage, at a caesarean section is very low, at around
0.03%.
National Institute for Health and Clinical Excellence. Caesarean Section. Clinical Guidance CG132. London:
NICE, 2011.
10. A False
B False
C True
Answers 153
D True
E False
Women with diabetes should have preconception counseling and advised of the
importance of achieving good glycaemic control prior to conception. They should
be advised to take 5 mg of folic acid daily prior to conception and continue this until
12 weeks’ gestation. They should be referred for retinal screening. If they are being
prescribed cholesterol-lowering drugs, these should be stopped.
Monthly haemoglobin A1C (HbA1C) measurement is recommended to ensure good
control prior to conception. If possible, women should aim for an HbA1C of 6.1% or
as close to it as possible to reduce the chance of congenital malformations. Women
whose HbA1C is above 10% should be strongly advised not to become pregnant.
National Institute for Health and Clinical Excellence. Diabetes in Pregnancy: Management of Diabetes and
its Complications from Preconception to the Postnatal Period. Clinical Guidelines CG63. London: NICE, 2008.
11. A True
B True
C True
D True
E False
Postpartum haemorrhage (PPH) can be considered as either primary or secondary. A
primary PPH is the loss of more than 500 mL of blood within 24 hours of delivery. A
secondary PPH is the loss of large volumes of blood which occurs between 24 hours
and 6 weeks after delivery.
The majority of PPHs are caused ultimately by uterine atony, which is more likely in
multiple pregnancy, polyhydramnios and prolonged labour. Abnormal placentation
is associated with increased risk of antepartum and postpartum haemorrhage.
Other risk factors for PPH include a previous history of PPH, previous antepartum
haemorrhage, multiparity and advancing maternal age.
Royal College of Obstetricians and Gynaecologists. Prevention and Management of Postpartum
Haemorrhage. Green-top Guideline 52. London: RCOG, 2009.
13. B
She is immune to chickenpox and no
further action needs to be taken
The incubation period of chickenpox is 1–3 weeks. Chickenpox is infectious from
48 hours before the rash appears and remains so until the vesicles crust over. If
a woman is not immune, varicella vaccination can be offered pre-pregnancy or
postpartum.
Women who are varicella zoster virus IgG-negative should avoid contact with
chickenpox and shingles in pregnancy. Varicella zoster immunoglobulin (VZIG)
should be given to non-immune pregnant women who have been exposed. VZIG
should not be given once chickenpox has developed.
Chickenpox in the first trimester does not increase risk of miscarriage.
Royal College of Obstetricians and Gynaecologists. Chickenpox in Pregnancy. Green-top Guideline 13.
London: RCOG, 2007.
19. D
Arrange the next available ultrasound scan
as an outpatient
Miscarriage is the most common complication of pregnancy. Threatened miscarriage
is defined as uterine bleeding with a closed cervix. It can affect up to 25% of
pregnancies. Clinical examination will reveal a soft, non-tender uterus.
An inevitable miscarriage is either complete or incomplete depending on whether
all the pregnancy tissue has been expelled from the uterus or not. An incomplete
miscarriage will present with ongoing bleeding, abdominal pain and an open cervix.
An early pregnancy assessment unit is an appropriate setting for referral of a
haemodynamically stable patient in early pregnancy. Women need to know that
until then an ectopic pregnancy cannot be excluded, and they must return earlier if
they experience severe pain or become unwell.
Royal College of Obstetricians and Gynaecologists. The Management of Early Pregnancy Loss. Green-top
Guideline 25. London: RCOG, 2006.
23. D
Low-molecular weight heparin therapy for
6 weeks postnatally
Any woman who has had only one thromboembolic event in the past, with no
other known risk factors, still needs to be monitored closely during her pregnancy. A
prophylactic dose of low molecular weight heparin is needed for 6 weeks after delivery.
Factor V Leiden is the most common inherited thrombophilic disorder. The risk of
thromboembolic events can be increased by approximately 30 times in individuals
who are homozygous for the disease.
This patient is most at risk of developing a thromboembolic event postnatally and
the most appropriate course of action is to give low molecular weight heparin for
6 weeks postnatally.
Royal College of Obstetricians and Gynaecologists. Reducing the Risk of Thrombosis and Embolism during
Pregnancy and the Puerperium. Green-top Guideline 37. London: RCOG, 2009.
158 Chapter 9 Clinical management
24. C
Insertion of a levonorgestrel-releasing
intrauterine system (IUS)
Endometrial hyperplasia is a premalignant condition and these patients are more
likely to develop endometrial carcinoma. One important cause is unopposed
oestrogens, therefore oestrogen-only hormone replacement therapy would be
contraindicated in this case. An ultrasound in 6 months time would not be the most
appropriate management as it is not a diagnostic tool, and would only be of benefit
to determine endometrial thickness. Use of progestogens helps to maintain a thin
endometrium and prevent development of endometrial cancer.
26. A
Auscultation of the fetal heart using a
handheld Doppler device
The perception of reduced fetal movement (RFM) is a common obstetric
presentation. In the majority of presentations of RFM, fetal well-being
is confirmed and the pregnancy goes on to have a successful outcome.
Nevertheless, the sudden reduction in fetal movements or cessation of any
movement perception must be taken seriously and is often reported by women
who have had a stillbirth. Between 24 and 28 weeks’ gestation the most
appropriate investigation is auscultation of fetal heart using a handheld Doppler
device. At this gestation there is neither role for cardiotocography (CTG) nor
ultrasound assessment (unless there are other concerns regarding fetal growth).
After 28 weeks a CTG is an appropriate method of assessing well-being. Prior
to 24 weeks’ gestation fetal well-being should be assessed using a handheld
Doppler device (as for pregnancies of 24–28 weeks’ gestation). The completion
of a 24-hour kick chart following normal investigation of fetal well-being is
not indicated at any gestation. Biophysical profiling is not indicated in low-risk
pregnancies with RFM. Any woman who has further episodes of RFM should be
advised to re-present to her care providers as soon as possible.
Royal College of Obstetricians and Gynaecologists. Reduced Fetal Movements. Green-top Guideline 57.
London: RCOG, 2011.
Chapter 10
Data interpretation
Questions: MCQs
Answer each stem ‘True’ or ‘False’.
Questions: SBAs
For each question, select the single best answer from the five options listed.
10. A 32-year-old multiparous pregnant woman attends the antenatal clinic for review
at 28 weeks' gestation. She mentions that her 4-year-old daughter has chickenpox.
She is unsure whether she has had chickenpox before. Serology results are as
follows:
Varicella zoster virus IgM: negative
Varicella zoster virus IgG: positive
What do the serology results suggest regarding her immune status with respect to
chickenpox?
A Acute episode of shingles
B Varicella zoster – chronic carrier
C Varicella zoster – current acute infection
D Varicella zoster – no acute infection, no previous exposure
E Varicella zoster – previous exposure
11. A 40-year-old primiparous woman is admitted and investigated for raised blood
pressure. Protein shows +++ on urine dipstick. A 24-hour urine collection is sent
for protein calculation.
What level of urinary protein excretion in 24 hours indicates significant
proteinuria?
A > 0.1 g
B > 0.2 g
C > 0.3 g
D > 0.4 g
E > 0.5 g
12. A 27-year-old primiparous woman presents with mild abdominal pain and some
vaginal spotting. Her last menstrual period was 5 weeks ago. Her serum β-human
chorionic gonadotrophin (β-hCG) on presentation is 258 IU/L. As she is clinically
stable, with no risk factors for ectopic pregnancy, she goes home and returns to the
early pregnancy unit 2 days later for a repeat serum β-hCG.
The results of her serial serum β-hCG as follows:
Day 1: β-hCG 258 IU/L
Day 3: β-hCG 460 IU/L
Which of the statements below best describes this patient’s serum β-hCG trend?
A Normal rise, cannot exclude ectopic pregnancy
B Normal rise, confirmatory of a viable intrauterine pregnancy
C Suboptimal rise, suggestive of early miscarriage
D Suboptimal rise, suggestive of ectopic pregnancy
E None of the above
13. A couple with primary subfertility, who have been trying to conceive for over
12 months, attend a reproductive medicine clinic. The male partner has already
given a semen sample for analysis. The results of semen analysis are as follows:
Questions: SBAs 163
19. A 54-year-old woman is investigated for abdominal bloating and weight loss. A
range of blood tests are sent as part of her investigations.
Which of the following serum levels would be increased if the she had
hepatocellular cancer?
A Alpha-fetoprotein
B CA 15-3
C Carcinoembryonic antigen
D Creatinine kinase
E Neurone specific enolase
21. A 32-year-old primiparous woman attends the maternity day unit at 34 weeks’
gestation complaining of itching of the palms of her hands. Her blood tests show
raised bile acids of 17 µmol/L. Her alanine aminotransferase is raised to 180 IU/L.
What is the most likely diagnosis?
A Alcoholic liver disease
B Dermat itis
C Gallstones
D Hepatitis B
E Obstetric cholestasis
23. A 25-year-old nulliparous woman attends cervical screening for the first time. The
results of her smear test show borderline nuclear changes.
What is the appropriate follow-up for this woman?
A Immediate referral to colposcopy
B Repeat smear in 1 year
C Repeat smear in 3 years
D Repeat smear in 3 months
E Repeat smear in 6 months
24. A 25-year-old primiparous woman has a forceps delivery. She sustains trauma to
the perineum. You perform a per rectal examination. You note that <50% of the
thickness of the external sphincter has been torn.
What grade of perineal tear has the patient sustained?
A Fourth degree tear
B Second degree tear
C Third degree tear – class A
D Third degree tear – class B
E Third degree tear – class C
A Abruption
B Placenta praevia
C Trauma
D Vasa praevia
E Uterine rupture
Answers
1. A True
B True
C True
D False
E False
A cardiotocograph (CTG) is a legal document and should therefore be appropriately
stored for 25 years. It should always be dated and timed, and labelled with the
woman’s details. See Table 10.1 for CTG classification.
Fetal blood sampling (FBS) should be considered if there is a pathological trace and
there are no contraindications. FBS may be performed in a fetus from 34 weeks’
gestation.
National Institute for Health and Clinical Excellence. Intrapartum Care. Clinical Guideline CG55. London:
NICE, 2007.
2. A False
B True
C False
D False
E True
168 Chapter 10 Data interpretation
3. A True
B True
C False
D True
E True
The differential diagnosis for proteinuria includes:
1. Pre-eclampsia: only significant once it reaches ≥0.3 g in 24 hours. May be
associated with other features including headache, visual disturbance and raised
blood pressure.
2. Normal pregnancy: proteinuria may be a normal finding in pregnancy due to
changes in the renal system including increased glomerular filtration rate and
increased protein excretion.
3. Urinary tract infection: including lower urinary tract infection and
pyelonephritis. There may also be leucocytes and nitrites on urine dipstick to
support evidence of infection.
4. Renal tract disease: may be associated with microscopic haematuria. Renal
damage may be as a result of diabetes or autoimmune conditions.
4. A True
B False
C False
D True
E False
Serum β-human chorionic gonadotrophin (β-hCG) monitoring is typically used to aid
the diagnosis and management of pregnancies of unknown location. An intrauterine
pregnancy, if present, should be visible on transvaginal ultrasound scan when the
serum β-hCG level is ≥1500 IU/L, although an early pregnancy may be visible at from
levels of around 1000 IU/L. Serum β-hCG is typically repeated 48 hours after the first
sample, and may be repeated at several 48 hourly intervals. A rise in β-hCG of at
least 66% every 48 hours is considered normal. A diagnosis of miscarriage or ectopic
Answers 169
of cystitis and ascending infection which may increase maternal or fetal morbidity.
Urinalysis should be performed on pregnant women routinely at all antenatal clinic
visits. The presence of protein, leucocytes and nitrites all suggest the presence of a
UTI. A renal ultrasound scan would only be indicated in the presence of recurrent
pyelonephritis or if renal abnormality or disease is suspected.
Royal College of Obstetricians and Gynaecologists. Chickenpox in Pregnancy. Green-top Guideline 13.
London: RCOG, 2007.
StratOG.net. Maternal Medicine: Infectious Diseases. London: StratOG, 2012. www.rcog.org.uk/stratog
11. C > 0.3 g
Urinary protein excretion of > 0.3 g in 24 hours indicates a significant level of
proteinuria. This may be found in conditions such as pre-eclampsia or pre-existing
renal disease. Severe proteinuria may not always be associated with significantly
raised blood pressure and may be due to long-standing renal damage and should be
investigated.
13. C
Reduced sperm count, with all other
parameters normal
The World Health Organization (WHO) has recently redefined the normal reference
ranges for semen analysis. A minimum of 15 million sperm/mL is acceptable as
per the WHO. This man’s sperm count is only 12 million sperm/mL and therefore
is considered to be suboptimal. A minimum of 4% of semen with normal
morphology is acceptable. The lowest acceptable volume of the ejaculate is 1.5 mL.
The total motility of a sample refers to the percentage of both progressive and
non-progressive forms. The WHO considers 40% to be the minimum acceptable
percentage for total motility. For the most accurate results analysis should be
performed within 60 minutes of production.
Cooper TG, Noonan E, von Eckardstein S, et al. World Health Organization reference values for human
semen characteristics. Hum Reprod Update 2010; 16(3):231–245.
14. A
Abnormal result, consider immediate delivery of baby
Fetal blood sampling (FBS) is a means of assessing fetal well-being when there
are concerns raised when using electronic fetal monitoring during labour. The
172 Chapter 10 Data interpretation
results of fetal blood samples are used to assess fetal hypoxia in the presence of
an accompanying pathological cardiotocograph (CTG). The normal fetal blood pH
range is 7.25–7.35. If a sample within this range in the presence of a pathological
CTG then a further FBS sample should be taken within 1 hour if the CTG remains
pathological. When the pH obtained is between 7.21 and 7.24 the result is classified
as borderline and a repeat sample should be taken within 30 minutes if the CTG
remains pathological. A sample with a pH of 7.20 or less is considered abnormal and
therefore immediate delivery of the baby should be considered.
National Institute for Health and Clinical Excellence. Intrapartum Care. Clinical Guideline CG55. London:
NICE, 2007.
16. D 3.5–5.0 mmol/L
The normal range for potassium in an adult human is 3.5–5.0 mmol/L. This value may
vary between hospitals. Hypokalaemia is a common abnormality in hyperemesis
gravidarum as a result of persistent vomiting and should be corrected to avoid
dangerous hypokalaemia.
19. A Alpha-fetoprotein
Alpha-fetoprotein is increased in hepatocellular cancer and active liver disease.
CA 15-3 is a non-specific tumour marker which may be raised in breast cancer.
Carcinoembryonic is generally increased in abdominal and gastric cancers. It may
also be increased in cirrhosis.
Neurone-specific enolase is raised in small cell cancer of the lungs.
20. C <4 mm
Bleeding after the menopause is a common presentation and should initially be
investigated using transvaginal ultrasound scan. An endometrial thickness of ≥4 mm
is abnormal and should be followed up with endometrial sampling, which may be
via pipelle biopsy or hysteroscopy. The majority of women with postmenopausal
bleeding are found to have atrophic endometrium, however there may be polyps,
hyperplasia or malignant change.
Bakour SH, Timmermans A, Willem B, et al. Management of women with postmenopausal bleeding:
evidence-based review. The Obstetrician & Gynaecologist 2012; 14(4):243–249.
the precursor of cervical cancer. The grading of CIN is based on the thickness of
the squamous epithelium affected (from the basal layer of the transformation zone
upwards). CIN I is the mildest form, only affecting the bottom third of the basal layer,
CIN II affects the bottom two-thirds of the squamous epithelium, whereas CIN III is
the most severe form of CIN and refers to changes affecting more than two-thirds to
full thickness of the epithelium (Table 10.3).
described as placenta which has inserted into the lower segment of the uterus, but
does not cover the cervical os. Major placenta praevia (previously classified as grade
III and grade IV) describes placental position when the placenta covers the cervical
os. Risk factors for placenta praevia include previous caesarean section, multiple
pregnancy and maternal age. The majority of antepartum haemorrhages are
idiopathic. Other causes include placental abruption, vasa praevia and local cervical
or vaginal pathologies.
26. E ≥22 cm
Polyhydramnios is an overall increase in liquor volume. It may be diagnosed if the
deepest pool of fluid seen on ultrasound scan is deeper than 8 cm or if the overall
amniotic fluid index (AFI) is > 22 cm. Causes of polyhydramnios include diabetes,
fetal anomalies causing problems swallowing and idiopathic causes.
Chapter 11
Immunology
Questions: MCQs
Answer each stem ‘True’ or ‘False’.
1. Antibodies:
A Are polypeptides
B Consist of two heavy and two light chains
C The antigen binding site is on the variable region
D The antibody binding site occurs on the light chain
E The largest antibody is IgG
2. Concerning hypersensitivity:
A Type II hypersensitivity is antibody dependent
B Type I hypersensitivity is associated with IgM activation
C The Arthus reaction is an example of type II hypersensitivity
D The Mantoux test is an example of type IV hypersensitivity
E Haemolytic disease of the newborn is an example of type II hypersensitivity
3. Concerning complement:
A The classical activation pathway is independent of antibody involvement
B The spleen is the main site of complement production
C Complement is a form of cytokine
D C3 is cleaved to C3a
E The alternative activation pathway requires binding of mannose-binding lectin
Questions: SBAs
For each question, select the single best answer from the five options listed.
Structure Properties
a Dimer Main immunoglobulin found in secretions, e.g. saliva, and mucosal
surfaces
b Monomer Antigen receptor on B cells
c Monomer Main mediator of allergic reaction
d Monomer Only immunoglobulin to cross the placenta
e Pentamer First immunoglobulin to be produced; expressed on surface of B cells
9. A female baby is born via spontaneous vaginal delivery at term. As she is born
in an urban area with high levels of tuberculosis she is given the BCG (Bacillus
Calmette–Guerin) vaccination before she is taken home by her parents.
What type of vaccine is the BCG vaccine?
A Conjugate vaccine
B Killed (inactivated) vaccine
C Live (attenuated) vaccine
D Subunit vaccine
E Toxoid vaccine
11. Which of the following is most important in the adaptive immune system?
A Complement
B Macrophages
C Natural killer cells
D Neutrophils
E T-helper cells
12. One of the known benefits of breastfeeding is its role in supporting the infant’s
immune system.
Which of the following antibodies is secreted in large amounts in breast milk?
A IgA
B IgD
C IgE
D IgG
E IgM
180 Chapter 11 Immunology
Answers
1. A False
B True
C True
D False
E False
Antibodies, also known as immunoglobulins, are glycoproteins, produced by
activated B cells. In humans there are five classes of antibodies, namely IgA, IgD,
IgE, IgG and IgM. Antibodies consist of two identical heavy polypeptide chains and
two identical light chains, which both contain a variable and a constant region. The
antigen binding site is made up of the variable regions of the light and the heavy
chain. The largest antibody is IgM, which is a pentamer, consisting of five joined IgG
units (Figure 11.1).
Constant
Fc region
domain
Heavy chains
2. A True
B False
C False
D True
E True
Hypersensitivity reactions are categorised according to the type of immune
response and traditionally are known as types I, II, III and IV. Type I hypersensitivity
reactions may also be referred to an immediate hypersensitivity; here the associated
allergen binds with IgE antibodies which are present on the surface of mast cells.
This leads to the activation of the mast cells leading them to degranulate and
release histamine into the circulation. This kind of reaction is typical in atopy
and at the extreme, anaphylaxis following exposure to allergens, e.g. peanuts.
Type II hypersensitivity is antibody dependent, whereby IgG and IgM antibodies
Answers 181
are stimulated by an allergen, which then activates the classical pathway of the
complement cascade. In haemolytic disease of the newborn maternal IgG crosses
the placenta and attacks fetal red blood cells. Other conditions associated with
type II hypersensitivity include pernicious anaemia and Goodpasture’s disease.
Type III hypersensitivity is associated with the deposition of immune complexes
(i.e. antibody-antigen complexes) in tissues. The Arthus reaction is an example of
type III hypersensitivity where there is localised vasculitis due to immune complex
deposition typically after booster immunisation with toxoid vaccines such as
tetanus. Type IV hypersensitivity is a delayed cell-mediated response to an antigen.
T cells are key to this reaction, and having been presented a specific antigen by cells
such as macrophages, they both secrete interleukins and activate macrophages to
produce cytokines. The Mantoux reaction is a form of type IV hypersensitivity where
there is localised induration of the skin at the site of tuberculin injection.
3. A False
B False
C False
D True
E False
Complement describes around 20 glycoproteins, the majority of which are produced
by the liver. The complement cascade is activated via three pathways. The classical
pathway requires binding of the complement C1 to an antibody molecule (either
IgM or IgG) which has been activated by an antigen to begin the cascade. The
alternative pathway begins with the activation of the complement protein C3; this
pathway does not require the presence of antibodies. The third pathway is the
mannose–lectin activation pathway, whereby carbohydrate residues on the surface
of pathogens activate circulating mannose-binding lectin (produced by the liver),
which then form a type of protease that is able to cleave complement and begin
the complement cascade. C3 is one of the complement proteins and as part of the
cascade (instigated by all three of the activation pathways), is cleaved to form C3a.
4. A False
B True
C True
D False
E True
Natural killer cells are a form of lymphocyte and are part of the innate immune
system. They are activated in several ways, e.g. in response to the presence of
cytokines released by infected cells, after antibody stimulation and also when there
is failure by cells to normally express the class 1 major histocompatibility complex
(as occurs in infected cells). They have strong cytotoxic activity and their main role
is in the destruction of cancerous cells or cells infected with viruses. Natural killer
cells kill by releasing perforin and granzyme from their cytoplasms which lead to
apoptosis in their target cells.
182 Chapter 11 Immunology
5. D Type II
Rhesus (Rh) D antigen is carried on erythrocytes. If a child is born to a Rh negative
mother and the father is Rh positive, he or she may express Rh D on their
erythrocytes. If fetal erythrocytes pass into the maternal circulation or if Rh D
positive blood is transfused into the mother, then sensitisation may occur; the
mother produces antibodies. In subsequent pregnancies fetal erythrocytes may
cross the placenta and stimulate a memory response, leading to the production of
IgG antibodies which destroy fetal erythrocytes. Anti-D immunoprophylaxis, using
anti-D immunoglobulin, during pregnancy and in the immediate postnatal period
prevents the development of maternal anti-D antibodies.
6. D
Monomer Only immunoglobulin to cross the placenta
Immunoglobulins, also known as antibodies, are formed by B cells. There are five
different classes of human immunoglobulin, which differ in both their structure
and function. Immunoglobin (IgG) is the predominant immunoglobulin found in
serum and is the only form of immunoglobulin that is able to cross the placenta
and therefore result in immunity in the fetus. It is also the longest living antibody
class, with a half life of around 3 weeks. There are four IgG subclasses. Named
IgG 1–4, this class of immunoglobulin is the predominant form involved in the
secondary immune response. IgG antibodies are good at fixing complement,
as well as opsonising targets, such as bacteria, for phagocytosis by cells such as
macrophages.
Cookson S, Sargent I. Chapter 19: Basic Immunology. In: Fiander A, Thilganathan B (eds). Your Essential
Revision Guide MRCOG Part 1. London: RCOG Press, 2010.
Pathogen C9
C3 Membrane
surfaces
C6 C7 C6 attack
B D complex
C5b
Mannose-binding lectin pathway
C5
C3b
Mannose- Opsonisation of
binding MBL pathogens
lectin binds
mannose on C3 Immune-complex
MASP-1 convertase removal
pathogen
MASP-2
surfaces
C2
C3a Recruitment of
inflammatory
C4 mediators and
C5a phagocytes
Classical pathway
Antigen- C1Q
antibody
complexes C1R
on pathogen
surfaces C1S
8. B Haemostasis
After an insult, the processes involved in acute inflammation are aimed at removing
the source of the trauma and encouraging healing. Acute inflammation is associated
with a series of vascular changes which aim to bring key components of the
inflammatory response to the site of injury. Vasodilation occurs rapidly after an insult
in response to mediators such as histamine. This leads to increased blood flow to the
traumatised area, with associated hyperaemia. Vascular permeability also increases,
allowing the passage of proteins, leucocytes and fluid from the vasculature into
the surrounding tissues. The movement of protein-rich fluid out of the vasculature
is associated with increased hydrostatic pressure. With a reduction in intravascular
volume there is an element of haemostasis, also contributing to local hyperaemia.
Both fibroblast infiltration and a high concentration of monocytes are typical of
chronic inflammation rather than acute.
live (attenuated) vaccines are MMR (mumps, measles, rubella), polio (Sabin) and
Bacillus Calmette–Guérin. Killed (inactivated) vaccines are generally considered
more stable and safer than live vaccines. However, as the immune response
to killed vaccines is generally weaker than to live vaccines, adjuvants such as
aluminium hydroxide are added to the killed vaccine in order to precipitate an
improved immune response. Examples of killed (inactivated) vaccines include the
hepatitis A, pertussis, influenza and polio (Salk) vaccines. Toxoid vaccines confer
immunity by the administration of inactivated toxin. Examples include the tetanus
and diphtheria vaccines which are often given in combination. Subunit vaccines
use specific antigens, in order to elicit an appropriate immune response. The
hepatitis B vaccine is one such subunit vaccine.
12. A IgA
Antibodies, or immunoglobulins, are glycoproteins produced by B cells as part of the
acquired immune system. The ‘default’ form of antibody is IgM, however each form of
antibody has a specialised function, and therefore they are differentially distributed
in line with their role in immunity (Table 11.1). The key to the acquired immune
system is the ability of B cells to switch class of antibody production in response
to the attacking antigen. IgA has key role in mucosal immunity and is therefore
the predominant antibody present in bodily secretions such as saliva, colostrum,
tears and is found in high concentrations in the respiratory, reproductive and
gastrointestinal tracts. Key to its functionality in inferring immunity to the neonate
is IgA’s resistance to stomach acid; this enables the capacity for IgA to be secreted in
breast milk and benefit the infant from its mother’s immunological memory.
Questions: MCQs
Answer each stem ‘True’ or ‘False’.
3. Concerning Neisseria:
A N. meningitidis is a Gram-positive cocci
B Infection with N. gonorrhoeae may cause a suppurative urethritis in males
C N. gonorrhoeae is a commensal of the genital tract
D N. gonorrhoeae thrives in conditions with low levels of carbon dioxide
E Species are cultured on chocolate agar
9. Bacterial toxins:
A Exotoxins are released from cell wall during bacterial cell death
B Exotoxins are released by Gram-positive and Gram-negative bacteria
C Endotoxins are a feature of Gram-positive bacteria
D Lipid A is responsible for the systemic features of endotoxic shock
E Gastrointestinal symptoms of cholera are caused by an endotoxin
11. Mycobacteria:
A Are obligate anaerobic bacteria
B Mycobacteria avium complex are found in patients with pre-existing lung
conditions
C M. leprae is effectively treated with amikacin
D M. kansasii can be found in indwelling central venous lines
E Are non-motile
Questions: SBAs 189
Questions: SBAs
For each question, select the single best answer from the five options listed.
12. A 50-year-old woman has ongoing pelvic pain; she has had a coil in situ for the last
8 years. She has a pelvic mass; histological sampling of the mass at laparoscopy
shows a suppurative and granulomatous inflammatory process with the presence
of sulphur granules.
Which is the most likely causative agent?
A Actinomyces israelii
B Chlamydia trachomatis
C Gardnerella vaginalis
D Neisseria gonorrhoeae
E Neisseria meningitidis
14. A 35-year-old man presents at a sexual health clinic with a new painless round
lesion on his penis; he also has non-tender inguinal lymphadenopathy.
What is the most likely causative agent of his symptoms?
A Chlamydia trachomatis
B Neisseria gonorrhoeae
C Treponema pallidum carateum
D Treponema pallidum pallidum
E Treponema pallidum pertenue
15. A 63-year-old man with an open fracture of the femur develops the rare
complication of gas gangrene and requires leg amputation.
What is the most likely causative agent?
A Clostridium botulinum
B Clostridium perfringens
C Clostridium tetani
D Escherichia coli
E Klebsiella pneumoniae
190 Chapter 12 Microbiology
16. A 28-year-old primiparous woman who is 16 weeks pregnant reports mild dysuria;
otherwise she is well. Urine dipstick shows leucocytes ++ and is positive for
nitrites. She is prescribed appropriate antibiotics.
What is the most likely causative organism of her urinary tract infection?
A Citrobacter freundii
B Escherichia coli
C Klebsiella pneumoniae
D Proteus mirabilis
E Staphylococcus saprophyticus
18. A 32-year-old primiparous school teacher is 16 weeks pregnant. She is seen in the
antenatal clinic, where she reports a maculopapular rash and coryzal symptoms.
The general practitioner has already sent serology and you review the result.
Rubella IgG: positive
Rubella IgM: negative
Parvovirus B19 IgG: negative
Parvovirus B19 IgM: positive
What is the most likely diagnosis?
A Non-immunity to parvovirus B19
B Non-immunity to rubella
C Recent infection with rubella
D Recent infection with parvovirus B19
E None of the above
21. A 23-year-old woman attends antenatal clinic at 22 weeks’ gestation. This is her
second pregnancy and she is very concerned as during her first pregnancy she had
an ‘infection’, which led to the permanent disability of her child. He is deaf, with
delayed development and is small for his age. He became jaundiced shortly after
birth.
What was the most likely cause of her son's condition?
A Cytomegalovirus
B Herpes
C Parvovirus B19
D Rubella
E Varicella zoster
22. A 38-year-old woman from Sri Lanka attends her general practitioner at 10 weeks’
gestation. She is complaining of fever and has pains in her joints. She developed
a rash yesterday. On examination, she has a temperature of 38.1°C, postauricular
lymphadenopathy and a maculopapular rash over her torso. Rubella is diagnosed.
What is the most likely fetal abnormality to occur as a result of this acute infection?
A Cerebral palsy
B Failure to thrive
C Limb hypoplasia
D Microcephaly
E Sensorineural hearing loss
23. A 15-year-old girl attends the genitourinary medicine clinic complaining of vaginal
itching and green vaginal discharge. She is sexually active with her 17-year-old
boyfriend and uses the oral contraceptive pill. Speculum examination reveals
haemorrhages on her cervix. A urine pregnancy test is negative.
192 Chapter 12 Microbiology
Considering the most likely diagnosis, what is the most appropriate first line
antibiotic?
A Azithromycin 1 g once only
B Doxycycline 100 mg twice daily + metronidazole 400 mg three times daily +
ofloxacin 400 mg twice daily for 7 days
C Doxycycline 100 mg twice daily for 14 days + metronidazole 400 mg three times
daily for 7 days
D Metronidazole 400 mg three times daily for 5 days
E Tinidazole 2 g once only
27. A woman presents at 28 weeks’ gestation with vomiting, headache, night sweats
and abdominal pain. She has recently returned from the African country of
Mali. Urgent blood films show the presence of Plasmodium falciparum, with a
parasitaemia of 3%. After a diagnosis of malaria has been made she is treated with
intravenous quinine.
Questions: SBAs 193
Answers
1. A False
B True
C False
D True
E True
The ability to Gram-stain bacterium allows classification into two major groups,
Gram-positive and Gram-negative. A bacterium which has peptidoglycan in its cell
wall will take up Gram-stain and therefore is considered Gram-positive. In addition
to Gram-staining, further simple classification of bacterium is based on appearance,
whether as cocci (i.e. spherical shaped), bacilli (i.e. rod shaped) and a further
classification of coccobacillus (intermediate shape) (Table 12.1).
Bacilli Cocci
Gram-positive Listeria species e.g. Staphylococcus species, e.g.
• L. monocytogenes • S. aureus
Clostridium species, e.g. Streptococcus species, e.g.
• C. botulinum • S. pneumoniae
• C. difficile • S. pyogenes
Actinomyces species, e.g. Enterococcus species, e.g.
• A. Israelii • E. faecalis
Mycobacterium species, e.g.
• M. tuberculosis
Gram-negative Escherichia species, e.g. Neisseria species, e.g.
• E. coli • N. gonorrhoeae
Enterobacter species e.g. • N. meningitidis
• Proteus mirabilis
Klebsiella species, e.g. Coccobacilli:
• K. pneumoniae Bordetella species, e.g.
Salmonella species, e.g. • B. pertussis
• S. enterica Brucella species
Shigella species, e.g. Haemophilus species, e.g.
• S. dysenteriae • H. influenzae
Campylobacter species, e.g.
• C. jejuni
Legionella species, e.g.
• L. pneumophila
Answers 195
2. A True
B False
C False
D True
E False
Group B β-haemolytic Streptococcus (GBS), also known as Streptococcus agalactiae,
is a common commensal in the gastrointestinal tract and is also part of normal
vaginal flora in around one-third of women. Although maternal vaginal carriage is
not itself harmful there is the risk of transmission to the baby with the potential to
cause neonatal sepsis once membranes rupture. GBS may also be associated with
chorioamnionitis.
GBS infection in infants is classified as having early onset (i.e. it occurs within the first
week of life) and late onset (occurs from the first week to the first few months of life).
Early-onset disease typically manifests as pneumonia, septicaemia and meningitis,
with the latter being more common when there is late-onset disease. It is not current
practice within the UK to routinely screen pregnant women for GBS. Nevertheless,
if GBS has been detected during the current pregnancy, standard practice is the
administration of intrapartum antibiotic therapy (a typical regimen being 3 g
intravenous penicillin G, followed by 1.5 g every 4 hours in labour).
Royal College of Obstetricians and Gynaecologists. Prevention of Early Onset Group B Streptococcal
Disease. Green-top Guideline 36. London: RCOG 2003.
3. A False
B True
C False
D False
E True
Neisseria are from the genus of aerobic Gram-negative cocci. Neisseria gonorrhoeae
and N. meningitidis are both human pathogens. Both species prefer a moist
environment with 5–10% levels of carbon dioxide.
Neisseria meningitidis is a commensal of the nasopharynx in around 10% of the
population, with higher carriage rates amongst teenagers. It is transmitted via
droplet spread of respiratory secretions and can lead to bacteraemia and meningitis,
with rarer manifestations including arthritis and osteomyelitis. Bacteriological
diagnosis of meningococcal meningitis requires culturing cerebrospinal fluid from
a lumbar puncture.
Neisseria gonorrhoea causes the sexually transmitted disease gonorrhoea. It can be
asymptomatic in up to 50% of women, and can lead to pelvic inflammatory disease.
Symptomatic individuals with gonorroheoa may present with lower abdominal pain,
increased or altered vaginal discharge or dysuria.
196 Chapter 12 Microbiology
British Association for Sexual Health and HIV. Management of Gonorrhoea in Adults, 2011. www.bashh.org
Health Protection Agency. Meningococcal Infection Factsheet. London: HPA, 2011. www.hpa.org.uk
4. A False
B True
C False
D True
E True
Viruses contain either DNA or RNA as their genetic material, which may be either
single-stranded (ss) or double-stranded (ds) (Table 12.2). Further classification
of their genetic material is dependent on the ‘sense’ of the strands, i.e. whether
positive-sense or negative-sense.
5. A False
B False
C False
D False
E True
The varicella zoster virus (VZV) is a double-stranded DNA virus and is a member of the
herpesviridae family. First exposure to the virus results in chickenpox, which manifests
around 2 weeks after exposure as a widespread vesicular rash and is often associated
with pyrexia and malaise. After the initial exposure the virus lays dormant in the
sensory root ganglia until it is reactivated, often after many years. Reactivation results
in shingles; here the reactivated virus travels down the nerve root it has infected and
causes inflammation. A characteristic rash and neuralgia is found with a dermatomal
distribution representing the affected nerve root. Antivirals such as acyclovir may be
Answers 197
given after 20 weeks’ gestation if the rash has been present for < 24 hours. If VZV is
contracted by a pregnant woman who has not been exposed to the virus previously
then she should urgently receive varicella zoster immune globulin. If exposure is close
to delivery there is a 50% chance that the fetus will become infected with VZV as there
is insufficient time for passive immunity to develop.
Royal College of Obstetricians and Gynaecologists. Chickenpox in Pregnancy. Green-top Guideline 13.
London: RCOG, 2007.
6. A True
B False
C True
D True
E False
Mononucleosis is caused by the Epstein–Barr virus, which is also known as human
herpesvirus 4. Bejel is caused by the spirochete Treponema pallidum endemicum and
should be distinguished from yaws which is caused by Treponema pallidum pertenue,
pinta caused by Treponema pallidum carateum and syphilis caused by Treponema
pallidum pallidum. Bacterial vaginosis is caused by a variety of bacterium including
Gardnerella vaginalis, Bacteroides and Mycoplasma. Sleeping sickness, also known as
African trypanosomiasis is caused by the transmission of the protozoal Trypanosoma
brucei via the tsetse fly. Dengue fever is caused by Dengue virus. Toxoplasma gondii
causes toxoplasmosis, which typically affects rodents and cats, but may lead to fetal
abnormalities such as intracranial calcification, chorioretinitis and miscarriage if
contracted for the first time during pregnancy.
7. A False
B True
C False
D False
E True
Preoperative antibiotic prophylaxis is now common practice. In order to be the most
effective, the antibiotic given needs to have the relevant spectrum of activity to
cover the organism(s) that may be found at the operative site. Removing hair with a
shaver leads to abrasions which may increase the chance of infection. Intraoperative
blood sugars should be kept below 11 mmol/L in patients with any type of diabetes
mellitus. The use of any prophylactic antibiotics, particularly more than one dose,
increases the risk of Clostridium difficile.
8. A True
B False
C True
198 Chapter 12 Microbiology
D False
E False
Cytomegalovirus (CMV) is a herpesvirus and is the most common cause of
congenital infection. Previous infection does not offer immunity, as both primary
and recurrent infection during pregnancy may lead to congenital infection.
The virus is spread through contact with infected body fluids. Both primary and
recurrent infections are often asymptomatic. Any symptoms that are experienced
are usually vague and include lethargy and fever. If conception occurs within 6
months of the primary infection, then the risk of placental transmission is higher.
The fetus may be affected by infection in any of the trimesters. Most babies who
have been congenitally infected show no signs or symptoms. However, those who
are affected may have jaundice, thrombocytopaenia, microcephaly, and motor
disorders. The main neurological sequelae are deafness and learning disabilities.
There is no CMV vaccine and antiviral drugs are not currently licensed for use to
treat CMV infection during pregnancy. Ganciclovir is sometimes used to treat
infection in babies and toddlers to help prevent hearing loss associated with
contracting CMV at this age.
9. A False
B True
C False
D True
E False
Toxins are produced by both Gram-positive and Gram-negative bacteria.
Exotoxins are produced by both Gram-positive and Gram-negative bacteria, whilst
endotoxins are constituents of the cell walls of Gram-negative bacteria. Table 12.3
gives further details.
Exotoxin Endotoxin
Producing bacteria Gram-positive Gram-negative
Gram-negative
Release Extracellular, released Structural molecule of Gram-negative
bacterial cell wall, released on cell
death
Examples of action Tetanus toxins Lipopolysaccharide
Cholera symptoms Lipid A
E. coli
Shigella
Antigenicity Susceptible to antibodies Limited effect of antibodies
Destroyed by heating
Answers 199
10. A False
B True
C False
D True
E True
Molluscum contagiosum is viral infection caused by the molluscum contagiosum
DNA poxvirus. It is usually a disease of the skin, but occasionally affects mucous
membranes. The lesions are painless and have a pearly-white appearance with a
dimpled centre. They are usually < 5 mm in diameter. It is spread through direct
contact and the fluid from the vesicles is infectious. Although most common
amongst children, it can also be sexually transmitted and may be mistaken for
genital warts. Individuals are infectious, whereas the lesions are present. Molluscum
is self clearing, but treatment may be expedited with cryotherapy or topical
treatments, such as benzoyl peroxide. Most cases are cleared within 6–9 months.
There is no immunity to the virus and it does not lie dormant within the body.
Health Protection Agency. Factsheet on Molluscum contagiosum. Essex: HPA, 2011. www.hpa.org.uk
11. A False
B True
C False
D True
E True
Mycobacteria are non-motile, obligate aerobic bacteria which are generally considered
to be Gram-positive. They are a group of bacteria subdivided into several complexes
and are generally associated with immunosuppressed individuals. Diagnosis is
performed via auramine staining and confirmatory testing is carried out with
Ziehl–Neelsen stain which stains mycobacteria pink. Mycobacterium avium complex
is associated with people with pre-existing lung conditions, including chronic
obstructive pulmonary disease, smoking and granulomatous disease. Mycobacterium
leprae (Hansen’s disease) causes classic symptoms leading to leprosy and systems
affected include skin, peripheral nerves and eyes. Dapsone is used to treat leprosy.
19. B Chorioamnionitis
The risk of vertical transmission of HIV is highest at delivery. In non-breastfeeding
untreated European women vertical transmission of HIV occurs in around 20%
of cases. Use of highly active anti-retroviral therapy (HAART) has reduced vertical
transmission in treated women to < 2%. Nevertheless, the management of the
delivery and postnatal period requires planning and a multidisciplinary team
approach. Prematurity, chorioamnionitis, prolonged rupture of membranes and
202 Chapter 12 Microbiology
21. A Cytomegalovirus
Cytomegalovirus (CMV) is the most common congenital infection. Pregnant women
often do not realise they have the infection as it is frequently asymptomatic.
Approximately 5–10% of congenitally infected babies have symptoms apparent
at birth which, if present, is a poor prognostic sign. Ten per cent of babies affected
at birth die and one-third develop cerebral palsy. Of the babies who are not
symptomatic at birth, approximately 1 in 6 are deaf, 1 in 10 have developmental
delay and 1% suffer from retinitis.
Bhide A, Papageorghiou AT. Managing primary CMV infection in pregnancy. BJOG 2008;115:805–807.
24. A Bacteroides
Obligate anaerobes are organisms that live and thrive in the absence of oxygen;
they will die in the presence of oxygen. Examples include bacteroides, Clostridium
and Actinomyces. By contrast, a facultative anaerobe is able to alter its function
depending on the presence or absence of oxygen. Examples include Staphylococcus
aureus, E. coli and Listeria.
25. B Isoniazid
Tuberculosis (TB) has a prevalence in the UK of 15–50/100,000 population, depending
on the location. The highest levels are currently in London. The disease most commonly
affects the lungs and 60% of infected individuals having pulmonary involvement.
TB may affect other organs including the genitourinary tract, which may present
with a pelvic mass or chronic pelvic inflammatory disease. This occurs as a result of
haematogenous spread from the primary location. Treatment of TB involves 6 months
of medication with rifampicin, isoniazid and pyrazinamide. Ethambutol has recently
been added to address the issue of resistance. Side effects of the medication include:
• Rifampicin: orange urine and tears, hepatotoxicity
• Isoniazid: hepatotoxicity, peripheral neuropathy (may be reduced by
administration of pyridoxine)
• Pyrazinamide: hepatotoxicity, gout
• Ethambutol: optic neuritis
National Institute for Health and Clinical Excellence. Tuberculosis. Clinical Guideline CG117. London: NICE,
2011.
26. E Ureaplasma
Endometritis may be acute or chronic. In this case, the patient has an acute
endometritis after caesarean section. Causes to be considered include retained
204 Chapter 12 Microbiology
products of conception and ascending infection from the lower genital tract, with
prolonged rupture of membranes being a particular risk factor. Acute endometritis
from an obstetric cause is most often polymicrobial, involving vaginal commensals.
These bacteria include Ureaplasma, Gardnerella and group B Streptococcus.
Other bacteria implicated in endometritis are those associated with sexually
transmitted infections including Chlamydia and gonorrhoea. Treatment includes
initial resuscitation and swift administration of broad spectrum antibiotics. Other
investigations include a full blood count, C-reactive protein, clotting profile and
pelvic ultrasound.
Hay PE. Chapter 22: Infections in Obstetrics and Gynaecology. In: Fiander A, Thilganathan B (eds).Your
Essential Revision Guide MRCOG Part 1. London: RCOG Press, 2010: 381.
Questions: MCQs
Answer each stem ‘True’ or ‘False’.
2. Choriocarcinoma:
A Is a malignant condition
B Is more common in women over 40 years old
C Can follow a normal pregnancy
D Most commonly metastasises to the lungs
E Syncytiotrophoblasts are filled with eosinophilic cytoplasm
4. Uterine fibroids:
A Are a risk factor for ovarian cancer
B Are usually benign in nature
C Are also known as leiomyomas
D Consist predominantly of fibrous tissue
E Can be treated by uterine artery embolisation
5. The following neoplasms are paired with the appropriate causative viruses.
A Burkitt’s lymphoma and Epstein–Barr virus
B Cervical cancer and human papillomavirus 2
C Kaposi’s sarcoma and human herpesvirus 8
D Hepatocellular carcinoma and hepatitis
E Testicular cancer and human T-lymphotrophic virus-1
206 Chapter 13 Pathology
9. Sarcomas:
A Are slow growing
B Include gastrointestinal stromal tumours
C Can metastasise to the lungs
D Originate from embryonic ectoderm
E Respond poorly to chemotherapy
10. Pheochromocytomas:
A Are corticosteroid producing tumours
B High levels of serum metanephrine can be diagnostic
C May present with severe hypertension and palpitations
D Originate from chromaffin cells
E Commonly develop in the renal cortex
D Noonan’s syndrome
E Xeroderma pigmentosum
14. Osteoporosis:
A Can be diagnosed when the bone mineral density T score is >1.5 standard
deviations from the mean
B Is more common in patients with Turner’s syndrome
C There is with increased osteoclast activity
D Sufferers have a normal Z score
E Can be coexistent with increased parathyroid hormone activity
17. Necrosis:
A Caseous necrosis can occur in the presence of Mycobacterium tuberculosis
B Is a natural sequelae of the cell cycle
C Leads to the release of inflammatory mediators
D Is reversible
E Involves nuclear changes including karyolysis
22. Metaplasia:
A Is synonymous with heteroplasia
B In the cervix it describes the change from columnar to transitional epithelium
C Is the change of one differentiated cell type to another
D Can be reversible
E Represents malignant change
Questions: SBAs
For each question, select the single best answer from the five options listed.
24. A 27-year-old nulliparous woman and her husband have a series of routine
investigations to investigate primary subfertility. She has a hysterosalpingogram
which shows she has a bicornuate uterus.
Which obstetric phenomenon is of increased prevalence in women with a
bicornuate uterus?
A Breech presentation
B Stillbirth
C Postpartum haemorrhage
D Placenta praevia
E Placenta accreta
26. In addition to mast cells, which of the following cells produces histamine?
A Basophils
B Erythrocytes
C Macrophages
D Monocytes
E Neutrophils
29. A 45-year-old woman is seen in the gynaecology outpatients’ clinic with a history
of severe menorrhagia. She has a body mass index of 42. An endometrial biopsy is
taken at hysteroscopy which shows evidence of simple endometrial hyperplasia.
Which of the following describes the type of cellular change that occurs in
hyperplasia?
A Increase in the number of cells
B Increase in the number of mitotic figures
C Increase in the number of nuclei in each cell
D Increase in the size of cells
E Increase in the thickness of the cell
31. A 43-year-old woman was diagnosed at 15 years of age with type 1 diabetes
mellitus. Her disease has been poorly controlled. She develops a non-healing ulcer
of her foot at age 35 years. By 40 years of age, she has an increasing serum urea
and a urinalysis shows a specific gravity of 1.012, pH 6.5, 1+ protein, no blood, 1+
glucose, negative leukocyte esterase, negative nitrite, and no ketones.
Which of the following renal diseases is she most likely to have?
A Crescentic glomerulonephritis
B Hyperplastic arteriolosclerosis
C Nodular glomerulosclerosis
D Papillary necrosis
E Pyelonephritis
32. A 59-year-old man presents with a 1-week history of frank haematuria. On physical
examination, there are no abnormal findings. Urinalysis confirms the presence of
blood, but no proteinuria or glucosuria. Urine culture is negative. A cystoscopy is
Questions: SBAs 211
performed, and a 3 cm exophytic mass is seen in the dome of the bladder. A biopsy
of this mass is performed and microscopic examination reveals fibrovascular cores
covered by a thick layer of transitional cells.
Which of the following risk factors is most likely to have led to development
of this lesion?
A Chronic use of nonsteroidal anti-inflammatory drugs
B Cigarette smoking
C Diabetes mellitus
D Recurrent urinary tract infection
E Obesity
33. A 30-year-old woman has had increasing malaise with fever, abdominal pain,
and weight loss of 3 kg over the past 3 weeks. On physical examination, her blood
pressure is 160/110 mmHg. She has a stool positive for occult blood. Urinalysis
reveals haematuria. She has no serum antineutrophil cytoplasmic autoantibodies
and her antinuclear antibody test is negative. Aneurysmal arterial dilations and
occlusions are seen in the medium-sized renal and mesenteric arteries with
angiography. She improves with corticosteroid therapy.
Which of the following is the most likely diagnosis?
A Benign nephrosclerosis
B Nodular glomerulosclerosis
C Polyarteritis nodosa
D Systemic lupus erythematosus
E Wegener granulomatosis
35. Which of the following is characteristic of the cellular changes seen in dysplasia?
A Absence of mitotic figures on microscopy
B Decreased mitotic activity
C Hyperchromatism
212 Chapter 13 Pathology
D Irreversibility
E Uniformity in cell shape
36. Which of the following vulval skin disorders is associated with the highest risk of
developing malignant disease?
A Contact irritant dermatitis
B Lichen planus
C Lichen sclerosus
D Squamous cell hyperplasia
E Psoriasis
37. A 75-year-old woman presents to her general practitioner (GP) with increasing
abdominal girth, reduced appetite and increasing shortness of breath. Her GP,
suspicious of malignancy, performs laboratory investigations and refers her for an
urgent review to the local hospital.
The results of her laboratory investigations are as follows:
From the tumour marker levels given what is the most likely primary tumour?
A Colorectal cancer
B Hepatocellular cancer
C Lung cancer with abdominal metastases
D Pancreatic cancer
E Primary peritoneal cancer
39. Which of the following is a risk factor for the development of ovarian cancer?
A Early menopause
B History of breastfeeding
C Nulliparity
D Oral contraceptive use
E Physical activity
Questions: SBAs 213
40. A grand multiparous woman has a postpartum haemorrhage soon after delivery.
She is tachycardic, hypotensive, with a capillary refill time of 3 seconds and she
appears confused. She has grade IV haemorrhagic shock.
What do you think is the estimated blood loss thus far based on clinical findings?
A 500 mL
B 750 mL
C 1000 mL
D 1300 mL
E 2000 mL
41. A 39-year-old woman has a forceps delivery. She is diagnosed as having a fourth
degree tear of the perineum, which is repaired in theatre. She is readmitted 5
days later with wound dehiscence and it is noted that faecal matter is draining
per vaginam. She has a temperature, is tachycardic and is feeling unwell. She is in
septic shock soon after arrival.
Which of the below pathogens is the most likely causative agent?
A Actinomyces israelii
B Clostridium perfringens
C Staphylococcus aureus
D Listeria monocytogenes
E Escherichia coli
214 Chapter 13 Pathology
Answers
1. A False
B False
C False
D True
E False
Mayer–Rokitansky–Küster–Hauser (MRKH) syndrome occurs in approximately
1 in 5000 females. The cause is unknown and it is not known to have a genetic
inheritance. Women affected have a female chromosomal pattern of 46XX and
normally-functioning ovaries. MRKH syndrome occurs as a result of abnormal
development of the Müllerian system which forms the uterus, fallopian tubes and
upper part of the vagina. There is a spectrum of abnormalities ranging from absence
of the proximal two-thirds of the vagina to more significant genital abnormalities
including absence of the uterus. It is not associated with hirsutism, but may be found
alongside abnormalities of the skeleton, kidneys and other organs.
2. A True
B True
C True
D True
E True
Choriocarcinoma is a malignant form of gestational trophoblastic disease which most
commonly occurs after a complete molar pregnancy. It is more common at extremes
of fertility: teenagers and those over 40 years of age. Pathology reveals sheets of
syncytiotrophoblasts and cytotrophoblasts with evidence of necrosis, haemorrhage
and intravascular growth. Treatment is carried out at specialist units and often requires
chemotherapy, however overall survival is good if metastasis has not yet occurred.
3. A False
B True
C False
D True
E True
Inflammation occurs in response to tissue injury. Acute inflammation occurs
immediately and may last hours or days, whereas chronic inflammation can potentially
last for months and years. In response to insult, a series of cellular and chemical
mediators become part of response aimed at removing the cause of the trauma and
bringing about tissue healing. Cytokines are cell-derived polypeptides, predominantly
produced by macrophages and lymphocytes as part of the inflammatory response. A
Answers 215
form of cytokines called colony stimulating factors act on the bone marrow to increase
the production of leucocytes. Fever is mediated by tumour necrosis factor (TNF) and
interleukin-1 (both cytokines), causing damage to the heat regulating system.
4. A False
B True
C True
D False
E True
Uterine fibroids, also known as leiomyomas, are benign growths of smooth muscle
which arise from the myometrium of the uterus. They can be classified according to
their location. Women with fibroids may complain of menorrhagia, dysmenorrhoea,
and problems with urinary frequency and hesitancy. In severe cases fibroids may be
associated with anaemia and urinary retention. Reduced fertility may be associated
with fibroids; the possible link between fibroids and recurrent miscarriage remains
unclear. Fibroids are more common in women of Afro–Caribbean origin and in
obese women. Treatment options include hormone therapy such as gonadotropin-
releasing hormone analogues to cause preoperative shrinkage, myomectomy,
uterine artery embolisation and hysterectomy. Rarely fibroids may undergo
malignant change and become leiomyosarcomas (Figure 13.1).
National Institute for Health and Clinical Excellence. Heavy Menstrual Bleeding. Clinical Guideline CG44.
London: NICE, 2007.
Subserosal
Intramural
Submucosal
Cervical
216 Chapter 13 Pathology
5. A True
B False
C True
D
true
E False
Epstein–Barr virus, also known as human herpesvirus 4, causes infectious
mononucleosis and is also associated with the development of neoplasms such as
Burkitt’s lymphoma, Hodgkin’s disease and nasopharyngeal carcinoma. The primary
cause of cervical cancer is infection by subtypes of the human papilloma virus
(HPV). By far the majority of cervical cancers are caused by the HPV subtypes 16
and 18. Kaposi’s sarcoma, an AIDs-defining illness, is caused by infection with human
herpesvirus 8. Hepatocellular carcinoma is associated with infection by hepatitis
viruses B and C, although it may also be caused by carcinogens such as aflatoxin B1
and may also be the sequelae of alcoholism and haemochromatosis.
6. A True
B False
C True
D True
E False
Vaginal clear cell carcinoma is a rare form of tumour associated with exposure to
diethylstilbestrol during fetal development. Several forms of leukaemia, i.e. acute
myeloid leukaemia and chronic lymphocytic leukaemia have been associated with
exposure to myelotoxic agents such as benzene. Exposure to aniline dye (also
known as benzidine) in factory workers is classically associated with the subsequent
development of bladder cancer. Similarly associated with bladder cancer is
β-naphthylamine, a carcinogen which is a constituent of cigarette smoke. A low-fibre
diet, high levels of processed meats and smoking are just a few of the risk factors
associated with the development of bowel cancer.
Chapter 25: Gynaeclogical Neoplasia. In: Fiander A, Thilganathan B (eds).Your Essential Revision Guide
MRCOG Part 1. London: RCOG Press, 2010: 404.
7. A True
B True
C False
D True
E False
Tumours may express receptors for certain hormones and therefore be considered
as hormone-dependant. Ductal carcinoma of the breast may be oestrogen
receptor-positive and can respond to oestrogen antagonist drugs such as tamoxifen.
Endometrial cancer may be considered a consequence of the effects of unopposed
Answers 217
Zuckerkandl (located at the bifurcation of the aorta), the neck and at other sites.
Pheochromocytomas secrete catecholamines, i.e. adrenaline and noradrenaline, and
are associated with high blood pressure (which may be malignant) and symptoms
such as palpitations, anxiety and headaches. Diagnosis may be made on the
finding of high levels of metanephrine in blood. High levels of urinary adrenaline,
noradrenaline, vanillylmandelic acid and homovanillic acid may also aid diagnosis.
The treatment of choice is surgical resection.
11. A True
B False
C False
D False
E True
Conn’s syndrome, a form of primary hyperaldosteronism, describes a series
of symptoms related to the excess production of aldosterone. Hypertension,
hypokalaemia and alkalosis may all be present. It may be caused by an aldosterone-
producing adenoma of the adrenal glands (Conn’s tumour) or hyperplasia of the
adrenal glands or may be idiopathic. Aldosterone’s action is at the distal tubule
and collecting duct of the kidneys, where it promotes the reabsorption of sodium
ions and water and the subsequent excretion of sodium ions. Excess aldosterone
therefore leads to abnormally low levels of potassium and volume expansion with
hypertension and its inevitable sequelae, e.g. heart failure. Treatment options
include surgery and the usage of aldosterone-antagonists such as spironolactone.
12. A True
B True
C False
D False
E True
Xeroderma pigmentosum and Cockayne’s syndrome are both conditions where
there is autosomal recessive inheritance of a defect in DNA repair. Such conditions,
which also include Bloom’s syndrome, Fanconi’s anaemia and Rothmund–Thomson
syndrome, are associated with accelerated ageing and with a higher risk of
developing certain forms of cancer. For example, individuals with xeroderma
pigmentosum are prone to skin cancers such as malignant melanoma due to a defect
in the ability to correct DNA damage caused by ultraviolet light. Cockayne syndrome
is associated with premature ageing, photosensitivity and growth problems.
13. A False
B False
C True
D False
E True
Answers 219
menopause. Risk factors for osteoporosis include: having a low body mass index,
smoking, calcium deficiency, excess alcohol intake, minimal exercise, family history
and corticosteroid usage. Osteoporosis is also common in states of hypogonadism,
e.g. in individuals with Kallmann’s syndrome. Prevention of osteoporosis is possible
by early recognition of modifiable risk factors such as smoking and low levels of
weight-bearing exercise. Individuals with osteoporosis may benefit from the usage
of bisphosphonates and calcium supplementation.
16. A True
B False
C True
D True
E False
Apoptosis is also known as programmed cell death. Essential for normal physiology,
apoptosis usually confers a biological benefit, such as tissue differentiation in
embryogenesis and the sloughing off of the endometrium during menstruation.
Apoptosis differs from necrosis, which is cell death following a form of trauma. In
apoptosis there are a series of sequential changes in the cell and its organelles.
During this energy-dependant process there is cell shrinkage followed by a series of
changes in the nucleus which include pyknosis, which refers to nuclear shrinkage
and condensation of chromatin, and karyorrhexis, which is the fragmentation of the
nuclei. In apoptosis there is formation of cytoplasmic blebs called apoptotic bodies.
Markers are expressed on the cell’s surface to encourage phagocytosis. The whole
process occurs without the release of inflammatory markers.
17. A True
B False
C True
D False
E True
Necrosis refers to the irreversible death of cells due to injury. There are a series of
changes that occur within necrotic cells. These sequential microscopic changes include
cytoplasmic eosinophilia, pyknosis (cell shrinkage), karyorrhexis (breakdown of the
nucleus) and karyolysis (complete dissolution of the nucleus secondary to the action
on DNAase). Necrosis is associated with the release of inflammatory mediators. There
are several types of necrosis, which are specific to the type of cell trauma and the tissues
involved; these include coagulative necrosis, caseous necrosis and colliquative necrosis. In
caseous necrosis a cheese-like matter is formed at the site of necrosis following infection
with Mycobacterium tuberculosis. Necrosis is not an inevitable event in the cell cycle.
18. A True
B False
C True
Answers 221
D True
E True
The Coombs test is used to detect serum antibodies directed against red blood
cells. The direct Coombs test detects the presence of antibodies or complement
on the red blood cell surface. The indirect Coombs test detects the presence of
unbound antibodies in the blood, which react in vitro against certain antigens.
Haemolytic disease of the newborn is an example of alloimmune haemolysis.
Warm antibody autoimmune haemolysis may occur in conditions such as systemic
lupus erythematosus. Cold antibody autoimmune haemolysis may occur in
conditions such as atypical pneumonias caused by bacterium mycoplasma,
infectious mononucleosis and paroxysmal cold haemoglobinuria. Administration of
methyldopa can cause a drug-induced, immune-mediated haemolysis and therefore
gives a positive direct Coombs test. Usage of cephalosporins can also give a positive
direct Coombs test.
19. A True
B False
C False
D True
E True
Protein C deficiency and factor V Leiden are both congenital conditions associated
with increased thrombus formation. Haemophilia A and haemophilia B (also known
as Christmas disease) are both sex-linked inherited disorders. Haemophilia A is
caused by a mutation in the factor VIII gene on the X-chromosome, with subsequent
factor VIII deficiency; haemophilia B is associated with factor XI deficiency due to
a gene mutation. Both haemophilias are associated with impaired clotting. In von
Willebrand’s disease there may be either a deficiency, or abnormality in the function
of von Willebrand Factor (vWF). vWF promotes platelet adhesion and sufferers may
experience varying levels of bleeding problems.
20. A True
B True
C True
D False
E False
Hyperplasia is the increase in the number of cells in a tissue and is easily confused
with hypertrophy, which is the increase in the size of cells. Hyperplasia can have
physiological benefit and may occur naturally in tissues, e.g. in the smooth muscle
of the pregnant uterus and in female breast tissue during puberty. In some
circumstances hyperplasia may be considered pathological, such as hyperplasia of
the adrenal cortex in Cushing’s syndrome, of the endometrium (due to unopposed
oestrogen) and in benign prostatic hypertrophy.
222 Chapter 13 Pathology
21. A True
B False
C False
D False
E False
Atrophy, (a diminution of the size of the cell, organ or part) and dysplasia may both
be reversible. Metaplasia is the conversion of a full differentiated cell type into
another differentiated cell type. Neoplasia refers to the abnormal proliferation of cells.
Neoplastic change may be malignant in nature, e.g. in breast cancer. However, there
are also benign neoplasms, e.g. uterine fibroids. Hypertrophy refers to the potentially
reversible increase in cell size, not number.
22. A False
B False
C True
D True
E False
Metaplasia represents the benign change from one form of differentiated type of
cell to another type of differentiated cell. Metaplasia typically occurs in response to
an irritant stimulus, whereby the cell type of a tissue changes in order to cope better
with the stresses of the irritant. This change in cell phenotype may be reversible,
especially when the ‘stressful stimulus’ is removed. Examples of metaplastic change
include the change from columnar epithelium to squamous epithelium in the
transition zone of the cervix, and the conversion of the squamous epithelium to
transitional epithelium in cases of Barrett’s oesophagus, which occur due to chronic
acid exposure. Although metaplastic change in itself is benign, persistent exposure
to irritants may eventually lead to dysplasia and potentially neoplastic change.
Heteroplasia describes the abnormal growth of cells in the wrong location in the
absence of any stimulus.
23. A False
B True
C False
D False
E True
Shock describes a state of acute circulatory failure leading to compromised organ
perfusion. Shock has various aetiologies and can occur secondary to anaphylaxis,
hypovolaemia, sepsis, obstruction and also cardiogenic causes. Regardless of the
cause, there are a number of characteristic features of shock which reflect the role of
the nervous and immune systems to compensate for this compromised state. These
features include tachycardia, hypotension, oliguria, reduced capillary refill time and
reduced levels of consciousness.
Answers 223
Uterus didelphus
Bicornuate uterus
Septate uterus
25. B 46 XX
Gestational trophoblastic disease describes a variety of conditions ranging from
complete and partial molar pregnancies to malignant choriocarcinoma. Histologically
there is cystic swelling of chorionic villi.
A complete molar pregnancy is usually caused by a single sperm combining with
an egg which is devoid of DNA. The genotype is usually diploid 46 XX, as a result of
mitosis of the fertilising sperm. Occasionally the genotype is 46 XY.
A partial molar pregnancy is usually caused by two sperm or one which duplicates
and has a triploid genotype 69 XXY, or quadraploid XXXY. Gestational trophoblastic
224 Chapter 13 Pathology
26. A Basophils
Histamine (5-hydroxytryptamine) is a significant contributor to the immediate
response in acute inflammation and is a vasoactive amine. It is predominantly
produced by local mast cells, but also by basophils and platelets. Histamine
is typically stored in mast cell granules and released during a process called
degranulation following mast cell activation. This activation may occur in response
to stimuli, such as mast cell antibody binding, following complement activation
and in direct response to injury. The main action of histamine is vascular dilatation,
however it is also involved in increasing vascular permeability.
cellular hyperplasia include the growth of glandular breast tissue during pregnancy,
endometrial hyperplasia and the hyperplasia of the adrenal cortex seen in Cushing’s
disease (Figure 13.3).
Hyperplasia Atrophy
34. D Rhabdomyolysis
This woman’s urinalysis shows myoglobinuria, which typically follows significant
trauma to muscle tissue. Although its presence may have minimal sequelae in severe
cases, there may be rhabdomyolysis. Myoglobin is normally renally-excreted, but in
excessive amounts it causes obstruction of the distal tubule and acute renal failure.
In rhabdomyolysis there is excessive release of the intracellular contents of muscle
cells leading to hyperkalaemia and metabolic acidosis. Hypocalaemia may also
occur. In severe cases there may be disseminated intravascular coagulation.
Answers 227
35. C Hyperchromatism
Dysplasia is a term used to describe abnormal development of immature cells in a
tissue, whereby there are abnormalities in the cellular architecture and appearance.
Dysplastic cells can be thought of as showing some of cellular changes that occur
in cancer cells. These atypical features infer malignant potential although not all
dysplastic tissue will go on to become malignant. In dysplastic cells a series of visible
characteristic changes occur which include:
• Increased mitotic activity
• Hyperchromatism: prominent cell nucleus due to increased chromatin
• Nuclear pleomorphism: abnormalities in the shape and size of the nucleus
• Anisocytosis: increased cell size
• Poikilocytosis: unusually shaped cells
Dysplasia may be reversible if in its early stages, especially if any causative stimulus
is removed. A potentially reversible form of dysplasia is present in CIN I, where
dysplastic changes are only seen in the basal third of the squamous epithelium; in
these cases there is high likelihood of reversible changes and monitoring may be
appropriate.
39. C Nulliparity
There are a series of risk factors for ovarian cancer. The main risk factors for the
development of ovarian cancer are increasing age, the presence of gene mutations
such as BRCA and HNPCC and a family history of the disease. Several additional risk
factors relate to ovarian activity, i.e. ovarian cancer appears to be less common
in women who have interrupted ovulation during their reproductive years. The
malignancy is more common in women who have an early menarche and a
late menopause. Women who have had no pregnancies are at a greater risk of
developing ovarian cancer; the more children a woman has had the lower the risk.
Protective factors include those who have used the contraceptive pill and those with
a history of breastfeeding.
40. E 2000 mL
This patient is obviously compromised by her blood loss and needs rapid fluid
resuscitation and is likely also to need blood products. Haemorrhagic shock can be
classified according to the amount of blood lost and the subsequent derangement
in vital signs as the body tries to compensate for the blood loss. In addition to
tachycardia, hypotension and tachypnea, there may be altered consciousness and
reduced urine output reflecting reduced organ perfusion. This patient’s condition
is suggestive a massive loss of blood volume, equivalent to around 2000 mL. This is
classified as class IV haemorrhagic shock:
• Class I haemorrhage: up to 15% blood volume, up to around 750 mL blood loss
• Class II haemorrhage: 15–30% blood volume lost
• Class III haemorrhage: 30–40% blood volume lost
• Class IV haemorrhage: over 40% blood volume lost
Questions: MCQs
Answer each stem ‘True’ or ‘False’.
1. Pharmacokinetics:
A Lipid soluble drugs are easily absorbed
B Bioavailability is the proportion of drug that reaches its target
C Fat soluble drugs can have a prolonged duration of action
D There are two phases of elimination of drugs from the kidney
E Phase II liver metabolism often involves cytochrome P450 enzymes
4. Opioid drugs:
A Leads to an increase in vasopressin release
B Cause pupillary dilation
C Morphine can cause hypotension associated with a reflex tachycardia
D Cannot cross the placenta
E Codeine is a more effective analgesic than dihydrocodeine
5. Anaesthetic agents:
A Halothane is an inhalational agent
B Nitrous oxide causes an increase in sympathetic nervous system activity
C Halothane can cause liver toxicity
D Isoflurane causes cardiac vasodilation
E Malignant hyperthermia is a side-effect of halogenated anaesthetic agents
232 Chapter 14 Pharmacology
6. Clomifene citrate:
A Can cause ovarian hyperstimulation
B Is an antioestrogen
C Can cause visual blurring
D Is taken during the luteal phase of the menstrual cycle
E Can be used for up to 18 months in women with anovulatory menstrual cycles
7. Cyproterone acetate:
A Is an antiandrogen
B Irreversibly inhibits spermatogenesis
C Is used to treat hirsutism
D Promotes cortisol synthesis
E Is linked to increased risk of thrombosis
8. Mifepristone:
A Is an antiprogestogenic steroid
B Is a folate antagonist
C Can be used for emergency contraception
D Decreases myometrial sensitivity to prostaglandins
E Can be used in the medical management of ectopic pregnancy
10. The following teratogens are correctly paired with the abnormalities they cause:
A Ramipril: polyhydramnios
B Phenytoin: spina bifida
C Diethylstilbestrol: vaginal clear cell adenocarcinoma
D Warfarin: hydrocephalus
E Danazol: masculinisation of the female fetus
Questions: SBAs 233
Questions: SBAs
For each question, select the single best answer from the five options listed.
11. Which of the following normal physiological changes seen in pregnancy are
associated with a slower drug metabolism?
A Delayed gastric emptying
B Increased body fat volume
C Increased cardiac output
D Increased glomerular filtration rate
E Increased third space volume
12. A 17-year-old girl discovers she is pregnant despite taking the oral contraceptive
pill. She has recently been prescribed a new medication by her general
practitioner.
Which of the following drugs is most likely to have interacted with the efficacy of
her contraception?
A Carbamazepine
B Cimetidine
C Erythromycin
D Metronidazole
E Sulphamethoxazole
13. Which of the following forms part of phase 2 reactions in drug metabolism?
A Conjugation
B Cyclisation
C Hydrolysis
D Reduction
E Oxidation
19. A 2-year-old child has been investigated by the ear, nose and throat specialists for
sensorineural hearing loss. Following a series of investigations he is found to have
a defect of the 8th cranial nerve.
Which of the following medications did his mother take during her pregnancy?
Questions: SBAs 235
A Chloramphenicol
B Co-trimoxazole
C Doxycycline
D Erythromycin
E Streptomycin
20. A 27-year-old woman is treated for severe bronchitis at 38 weeks’ gestation. Her
baby, born at 41 weeks’ gestation, has neonatal haemolysis.
Which drug taken by the mother for bronchitis is the cause of the baby’s neonatal
haemolysis?
A Amoxicillin
B Chloramphenicol
C Co-trimoxazole
D Doxycycline
E Erythromycin
22. A 25-year-old nulliparous woman, with a lifelong history of tonic clonic seizures,
sees her neurologist as she wishes to start a family. In addition to her current
anticonvulsant therapy which additional drug is now required?
A A second anticonvulsant
B Ferrous sulphate
C Folic acid
D Low-molecular weight heparin
E Vitamin K
23. A 23-year old woman is 8 weeks pregnant. She has persistent itchy, thick, white
vaginal discharge. A high vaginal swab has identified the presence of yeast species.
She has already tried topical clotrimazole cream which has provided no relief of
her symptoms.
Which is the most appropriate treatment for vaginal candidiasis unresponsive to
clotrimazole cream?
A Clotrimazole pessary
B Metronidazole 400 mg orally
C Fluconazole 400 mg orally
D Hydrocortisone 0.5% cream
E Trimovate creams
236 Chapter 14 Pharmacology
Answers
1. A True
B False
C True
D False
E False
Pharmacokinetics refers to the processes of drug absorption, distribution and
elimination. Drug distribution is dependent on the bioavailability and volume that
the drug is distributed in.
Lipid soluble drugs are easily absorbed as they cross membranes easily.
Bioavailability refers to the amount of drug which enters the circulation before any
change occurs to it. Fat soluble drugs are more widely distributed and often have a
prolonged duration of action as they are stored in the fat tissue.
Elimination of drugs occurs via the kidneys and liver. In the presence of liver or
kidney dysfunction, the drug dosage may need altering.
Hepatic elimination occurs in two phases:
• Phase I: reduction, oxidation or hydrolysis which changes the drug to an active,
inactive or toxic state
• Phase II: drugs become more soluble by conjugation, e.g. with glucuronate, and
they can then be excreted in urine
2. A True
B True
C False
D True
E False
Enzyme inducers:
• Griseofulvin
• Phenytoin
• Phenobarbitone
• Rifampicin
• Carbamazepine
• Ethanol
Enzyme inhibitors:
• Metronidazole
• Ciprofloxacin
• Fluconazole
• Erythromycin
Answers 237
• Ethanol (acute)
• Cimetidine
• Amiodarone
• Ketoconazole
3. A False
B True
C True
D True
E False
Pain is a subjective sensation. Prostaglandins enhance the pain sensation produced
by other chemicals, e.g. serotonin; however, they are not themselves a direct cause
of pain. By blocking potassium channels, prostaglandins make nerve terminals more
sensitive to pain. Bradykinin is a peptide which acts as a potent mediator of pain.
Prostaglandins work together with with bradykinin to increase its action at nerve
terminals. 5-HT (serotonin) is a transmitter of inhibitory neurons. Glutamate is an
excitatory amino acid. It is released from primary afferent neurons and is responsible
for fast synaptic transmission and slow receptor-mediated responses. Adenosine has
a role in both activation and inhibition of pain transmission.
4. A True
B False
C False
D False
E True
Opioid drugs affect many body systems and at a cellular level and exert their
actions via G-protein coupled receptors which inhibit adenylate cyclase and reduce
cAMP content. They cause an opening of potassium channels and thereby affect
the neuronal excitability. Morphine may cause hypotension which is not usually
accompanied with a reflex tachycardia. Other effects of opioid analgesics include
respiratory depression, papillary constriction and vomiting (stimulation of the
chemoreceptor trigger zone). Morphine and other opioid drugs cause an increase in
vasopressin (antidiuretic hormone) release. Opioid drugs readily cross the placenta
and this is the mechanism by which newborns can be affected by administration
of pethidine, if given soon before delivery. Codeine is a more potent analgesic than
dihydrocodeine.
5. A True
B True
C True
D True
E True
238 Chapter 14 Pharmacology
7. A True
B False
C True
D False
E True
Cyproterone acetate is an antiandrogen, which also causes a negative feedback to
hypothalamic receptors leading to reduced production of both gonadotrophins
and testosterone. It is used in the treatment of advanced prostate cancer, in cases
of severe male hypersexuality, for hirsutism and acne in women and to treat hot
flushes, where other methods have failed. Cyproterone acetate may be combined
with ethinylestradiol in the form of co-cyprindiol, trade name Dianette, for women
with severe acne or hirsutism who also require contraception. This combination of
cyproterone acetate with an ethinylestradiol is associated with an increased risk of
thrombosis. During administration it is known to reversibly inhibit spermatogenesis.
Known side effects include hepatotoxicity, gynaecomastia, low cortisol, low
aldosterone and osteoporosis. Administration of cyproterone acetate requires close
monitoring of liver function.
Anantharachagan A, Sarris I, Ugwumadu A. Revision Notes for the MRCOG Part 1. Oxford: Oxford
University Press, 2011: 333.
8. A True
B False
C True
D False
E False
Mifepristone is an antiprogestogenic steroid which acts as a competitive
progesterone receptor antagonist. It is used in the medical termination of
pregnancy, where it acts to cause endometrial decidual degeneration, increase
myometrial sensitivity to prostaglandins such as misoprostol (which are often given
alongside the mifepristone), ripen the cervix and increase release of endogenous
prostaglandins. Theoretically mifepristone can be used as an emergency
contraceptive, where it is thought to both delay ovulation and prevent implantation.
9. A True
B False
C True
D True
E False
Cytotoxic antibiotics are used in the treatment of malignancy due to their ability to
inhibit DNA and RNA synthesis. Doxorubicin inhibits both DNA and RNA synthesis
240 Chapter 14 Pharmacology
and also interferes with the action of topoisomerase II action, which is highly active
in rapidly replicating cells. Bleomycin is a metal-chelating glycopeptide antibiotic
which damages cells via DNA strand breakage. It is able to also work on non-dividing
cells and is used to treat malignancies such as testicular cancer. Dactinomycin
incorporates itself into the DNA chain, where it prevents effective movement of RNA
polymerase and subsequently inhibits transcription. Fluorouracil is not a cytotoxic
antibiotic but an antimetabolite which is a uracil analogue. Vinblastine is a plant
alkaloid which interferes with the microtubules of dividing cells and therefore
inhibits mitosis.
10. A False
B True
C True
D False
E True
Ramipril taken during pregnancy has been associated with fetal renal failure,
oligohydramnios and skull defects and therefore alternative antihypertensives
should be given to pregnant women. Phenytoin is an antiepileptic drug which is an
antagonist of folate; folate is essential for DNA synthesis. Use of phenytoin during
pregnancy has been linked to defects in fetal neural tube development such as
spina bifida, in addition to fetal hydantoin syndrome where developmental delay
and deformities such as microcephaly have been reported. Stilbestrol, also known
as diethylstilbestrol, was given to pregnant women up until the 1970s. Indications
for its use included the prevention of miscarriage in those with a history of recurrent
pregnancy loss. It was banned in the 1970s after exposure was associated with
the subsequent development of vaginal clear cell adenocarcinoma and other
abnormalities of the female genital tract in those exposed to the drug in utero.
Warfarin is thought to be teratogenic if given in the first trimester. It is known to
lead to abnormalities such as deformities of the fetal face and nose, axial skeletal
abnormalities and mental retardation. Exposure in the third trimester is associated
with abnormalities of the central nervous system such as seizures and cerebral
haemorrhage at delivery. Danazol is a synthetic form of testosterone and causes
virilisation of fetal genitals.
12. A Carbamazepine
Carbamazepine is an enzyme inducer. Drugs acting as enzyme inducers increase
the action of the enzyme system and lead to increased metabolism and therefore
clearance of the drug. In this case, the oral contraceptive pill has been less effective
due to the co-administration of an enzyme inducer. The rest of the drugs on this list
are enzyme inhibitors. Enzyme inhibitors increase the concentration and availability
of other drugs as they prevent their metabolism.
Other enzyme inducers are rifampicin, ethanol and carbamazepine.
13. A Conjugation
The process of elimination of a drug from the body is an irreversible process and
occurs via metabolism and excretion. Drug metabolism occurs via phase 1 and
phase 2 reactions, which both normally take place in the liver. Phase 1 reactions
include oxidation, reduction or hydrolysis, with the resulting products being more
reactive. Phase 2 reactions generally involve conjugation, e.g. with amino acids,
leading to inactivation of the drug. Some of the products are excreted in bile after
the phase two reaction.
14. B Aspirin
A large dose of aspirin results in uncoupling of oxidative phosphorylation which
leads to higher consumption of oxygen and increased carbon dioxide. The
higher carbon dioxide results in stimulation of the respiratory centre, causing
hyperventilation and a respiratory alkalosis. Higher doses of salicylates can cause
respiratory depression and produce respiratory acidosis. Increased temperature may
result from an increased respiratory rate. Aspirin is a non-steroidal anti-inflammatory
and in normal doses is an effective antipyretic and analgesic.
Overdose of amitriptyline can cause nausea and vomiting, but may also have more
serious side effects such as cardiac arrhythmia, agitation and unconsciousness.
Tramadol is an opioid and zopiclone is a benzodiazepine. Both of these medications
would lead to respiratory depression, but are unlikely to lead to a respiratory
alkalosis or hyperpyrexia.
15. B
Start prophylactic dose low-molecular weight
heparin (LMWH) immediately
Pulmonary embolism (PE) during pregnancy is responsible for the greatest number
of maternal deaths in the UK (1.56/100,000 pregnancies). It is therefore essential that
any woman who is clinically at risk of developing PE in pregnancy is recommended
appropriate prophylaxis. The Royal College guideline recommends that antenatal
thromboprophylaxis with LMWH is offered if there is a history of VTE in one of the
following categories: recurrent, unprovoked, oestrogen-related, pregnancy-related,
or associated with significant risk factors such as a documented thrombophilia.
242 Chapter 14 Pharmacology
In this case, the most appropriate answer is to start low-molecular weight heparin
immediately. It should be started from the first trimester, however in cases where this
has been missed; prophylactic dose should be commenced immediately. This patient
should also be referred urgently to haematology, but this is not the best answer.
Bourjeily G, Paidas M, Khalil H, Rosene-Montella K, Rodger M. Pulmonary embolism in pregnancy. Lancet
2010;375(9713):500–12.
Royal College of Obstetricians and Gynaecologists. Reducing the Risk of Thrombosis and Embolism During
Pregnancy and the Puerperium. Green-top Guideline 37a. London: RCOG
16. E Thrombocytopaenia
Heparin prevents coagulation via the activation of antithrombin III. Binding of
heparin to the antithrombin III changes its conformation and thereby speeds up its
rate of action. There are several potential side effects of heparin and these include:
• Bleeding: treated by stopping heparin therapy and treating with protamine
• Thrombocytopaenia: may be caused by IgM or IgG antibodies against circulating
platelets
• Hypoaldosteronism: may be associated with hyperkalaemia, rather than
hypokalaemia
• Osteoporosis: usually associated with long-term therapy. The mechanism of this
is unknown
17.
A Unaffected Prolonged Prolonged Unaffected
B represents haemophilia, C represents warfarin, D represents disseminated
intravascular coagulation while E represents thrombocytopaenia.
von Willebrand’s disease is a common inherited haemostatic disorder, with an
incidence of 1 in 10,000. It is autosomally inherited and is prevalent equally in males
and females. There are several types of disease; the most common is type I which
shows autosomal dominant inheritance. von Willebrand’s disease is a deficiency in
von Willebrand’s factor, a protein which brings platelets into contact with damaged
subendothelium, causing platelet adhesion and is essential for normal clotting.
Patients often present with an abnormality of bleeding which may manifest as nose
bleeds, abnormal menses or easy bruising. Females often present with menorrhagia.
The overall platelet count is not affected. These patients should not be given
non-steroidal anti-inflammatories due to the prolonged bleeding time. Clotting
profile may demonstrate a raised activated prothrombin time (APTT); however, the
international normalised ratio and platelets are usually normal.
18. B Ergometrine
Drugs that contract the uterus are as listed below.
• Oxytocin: is released from the posterior pituitary gland; can be given as an
intravenous infusion to augment labour or postpartum to prevent or treat
postpartum bleeding.
Answers 243
19. E Erythromycin
The aminoglycosides, such as gentamicin and streptomycin, are known to
damage the fetal 8th cranial nerve and are ototoxic when given in the second
and third trimesters. The greatest risk to the fetus occurs with streptomycin,
which has been associated with an incidence of 8th cranial nerve damage of
> 10%. Gentamicin may be required during pregnancy, e.g. in severe urinary
tract infections and should be given cautiously if indicated. In addition to the
risks to the fetus, the aminoglycosides are associated with both ototoxicity and
nephrotoxicity in adults.
20. C Co-trimoxazole
Historically, sulphonamides such as sulfadiazine were thought to increase the risk of
neonatal kernicterus via displacement of bilirubin from albumin binding sites; however,
this is now thought to be an unsubstantiated concern. Both the sulphonamides and
trimethoprim are thought to cause neonatal haemolysis and methaemoglobinaemia
and therefore should be avoided in third trimester. Co-trimoxazole, a mixture of the
sulphonamide sulphamethoxazole and trimethoprim, is therefore to be avoided
in pregnancy. In addition to the risks associated with the administration of these
antimicrobials in the third trimester, trimethoprim is known to be teratogenic during
the first trimester of pregnancy due to its action as a folate antagonist.
There are 30 multiple choice questions and 60 single best answer questions in this
paper. The paper should be sat in exam conditions and completed in two and a half
hours.
Questions: MCQs
Answer each stem ‘True’ or ‘False’.
3. The rectum:
A Commences at the level of the first sacral vertebrae
B Is about 25 cm in length
C Drains lymph to the preaortic nodes
D Is lined by columnar epithelium
E The posterior wall of the pouch of Douglas forms the anterior peritoneum
of the upper two-thirds of the rectum
13. Hirsutism:
A Is associated with polycystic ovary syndrome
B Is a recognised side effect of cyproterone acetate
C Can be pathognomonic of certain ovarian tumours
D Can be caused by hypothyroidism
E Can be treated by spironolactone
16. Vitamin D:
A Is a steroid hormone
B Undergoes 25-hydroxylation in the kidney
C Is stored in the liver
D Undergoes 1α-hydroxylation in the liver
E Its synthesis is influenced by cortisol
21. The following genetic disorders are correctly paired with the affected
chromosome:
A Cystic fibrosis: chromosome 7
B Duchenne muscular dystrophy: X chromosome
C Neurofibromatosis type 1: chromosome 22
D Prader–Willi syndrome: chromosome 16
E Sickle-cell disease: chromosome 11
Questions: SBAs
For each question, select the single best answer from the five options listed.
31. Which muscle lies within the rectus sheath and is supplied by the subcostal nerve?
A External oblique
B Internal oblique
C Pyramidalis
D Rectus abdominis
E Transversus abdominis
32. Which muscle enters the abdomen behind the medial arcuate ligament?
A External oblique
B Iliacus
C Psoas
D Pyramidalis
E Transversus abdominis
34. Which artery is the terminal branch of the internal thoracic artery?
A Inferior mesenteric artery
B Inferior phrenic artery
C Lumbar artery
D Superior epigastric artery
E Superior mesenteric artery
35. Which artery arises from the posterior trunk of the internal iliac artery?
A Inferior gluteal artery
B Middle rectal artery
C Superior gluteal artery
D Superior vesical artery
E Uterine artery
36. A 41-year-old woman complains of prolonged numbness in her leg 2 days after a
normal vaginal delivery. She had an epidural for pain relief during labour.
What is the nerve root origin of lateral cutaneous nerve of the thigh?
A L1
B L2
Questions: SBAs 251
C L3
D L1 and L2
E L2 and L3
37. A 25-year-old woman has a routine smear test for the first time. She complains of
discomfort during the procedure.
Which nerve or nerve plexus carries afferent fibres from the cervix to the upper
sacral nerves?
A Inferior hypogastric plexus
B Obturator nerve
C Pelvic splanchnic nerves
D Pudendal nerve
E Superior hypogastric plexus
38. A 72-year-old woman is referred to the gynaecology outpatient clinic with a 2-day
history of postmenopausal bleeding. She subsequently undergoes a hysteroscopy
and endometrial biopsy as part of her investigation.
Which of the following best describes the cells that line the uterus?
A Columnar epithelium
B Cuboidal epithelium
C Pseudostratified columnar epithelium
D Stratified squamous epithelium
E Transitional cells
42. Which of the following is correct regarding the embryological origin of the
anal canal?
A Above pectinate line: derived endoderm, superior rectal artery
B Above pectinate line: derived ectoderm, superior rectal artery
C Above pectinate line: derived ectoderm, columnar epithelium
D Below pectinate line: derived ectoderm, superior rectal artery
E Below pectinate line: derived endoderm, middle and inferior rectal artery
43. Prior to a forceps delivery, you wish to give a pudendal nerve block.
Where is the pudendal canal?
A Lateral wall of ischiorectal fossa; above sacrotuberous ligament
B Lateral wall of ischiorectal fossa; below sacrospinous ligament
C Lateral wall of ischiorectal fossa; below sacrotuberous ligament
D Medial wall of ischiorectal fossa; above sacrospinous ligament
E Medial wall of ischiorectal fossa; below sacrotuberous ligament
45. A 26-year-old woman attends her general practitioner for her 6 week postnatal
check. She has a central abdominal protrusion which is diagnosed as a divarication
of the rectus muscle.
What is the nerve supply to the rectus abdominis muscle?
A T2–T12
B T7–T12
C T12–L3
D L2–L5
E L5–S3
and it is noticed that he has an abnormal gait, with slightly bent and shortened
legs.
What is the most likely diagnosis of this child?
A Congenital abnormality
B Osteopetrosis
C Perthes disease
D Rickets
E Scurvy
47. A 65-year-old man attends his general practitioner with a 3-month history of lower
backache and fatigue.
Blood tests are as follows:
Urea 13.2 mmol/L
Creatinine 145 μmol/L
Potassium 5.9
mmol/L
Haemoglobin 9.8
g/dl
Mean corpuscular volume 82.2 fL/red cell
Calcium 2.65 mmol/L
What is the most likely diagnosis?
A Bone metastases
B Immobilisation
C Multiple myeloma
D Sarcoidosis
E Thiazide diuretics
Considering the most likely diagnosis, which is the most likely result?
A pH 6.9, pCO2 7.5 kPa, pO2 15.1 kPa, HCO3 15.4 mmol/L, base excess
-12 mmol/L
B pH 7.16, pCO2 8.2 kPa, pO2 8.8 kPa, HCO3 21.2 mmol/L
C pH 7.36, pCO2 5.6 kPa, pO2 13.2 kPa, HCO3 26 mmol/L
D pH 7.50, pCO2 3.0 kPa, pO2 9.2 kPa, HCO3 25 mmol/L
E pH 7.52, pCO2 6.0 kPa, pO2 12.0 kPa, HCO3 17 mmol/L, base excess +4.5
53. A 27-year-old woman is admitted to hospital with acute left iliac fossa pain, a
positive pregnancy test and a haemoglobin level of 7.9 g/dL. She undergoes a
diagnostic laparoscopy and is found to have an ectopic pregnancy.
Questions: SBAs 255
54. A 28-year-old woman is admitted to hospital with acute-onset right iliac fossa pain.
She has low-grade pyrexia and is nauseous. Her blood tests reveal a C-reactive
protein of 62 mg/dL and white cell count of 17.2 × 109/L. A diagnostic laparoscopy
reveals a Meckel’s diverticulitis.
Meckel’s diverticulum is the persistence of which structure?
A Urachal remnant
B Vitellointestinal duct
C Primitive streak
D Paraxial mesoderm
E Buccopharyngeal membrane
55. Which one of the following is a derivative of the urogenital sinus in male?
A Vas deferens
B Epididymis
C Ejaculatory duct
D Prostate
E Seminal vesicle
57. After an uneventful pregnancy a baby is born via spontaneous vaginal delivery. Soon
after birth the midwife asks the paediatric team to review the baby as she is uncertain
of the infant’s sex. Following a series of investigations the baby is found to have the
genotype 46XX and is diagnosed with congenital adrenal hyperplasia (CAH).
CAH is most commonly associated with a deficiency of which enzyme?
A 5α-reductase
B 11β-hydroxylase
C 17α-hydroxylase
256 Chapter 15 Mock paper 1
D 21α-hydroxylase
E Aromatase
58. A 26-year-old woman complains of increased facial hair and thinks it may be
caused by a new medication she was prescribed 3 months previously.
Which of the following drugs is known to cause hirsutism?
A Dianette
B Erythromycin
C Gentamicin
D Phenytoin
E Tacrolimus
62. A 63-year-old man attends his general practitioner with a 2-month history of lower
back pain associated with radiation of pain down the right leg and shortness of
breath. He has also lost some weight. Blood tests reveal:
Calcium 2.72 mmol/L
Haemoglobin 10.4 g/dL
Mean corpuscular volume 83.6 fL
Which of the following is the most likely diagnosis?
A Bone metastases
B Immobilisation
C Osteoporosis
Questions: SBAs 257
D Multiple myeloma
E Sarcoidosis
63. A junior doctor is asked to check the calcium levels on a patient 6 hours after a
removal of her parathyroid gland.
Which of the following is a function of parathyroid hormone (PTH)?
A In bone, PTH reduces osteoclast activity
B PTH acts in the kidney to reduce bicarbonate excretion
C PTH acts on the kidney to increase level of phosphate absorption
D PTH acts to reduce serum levels of calcium
E PTH acts via a G-protein coupled receptor
64. Calcium is transferred from maternal circulation to fetal circulation via which
transport mechanism?
A Active transport
B Endocytosis
C Exocytosis
D Facilitated diffusion
E Passive diffusion
65. Which of the following is true regarding maternal calcium homeostasis during
pregnancy?
A Increased calcitonin
B Reduced 1,25 vitamin D3
C Reduced bone turnover
D Reduced calcium absorption
E Reduced parathyroid hormone production
66. Which of the following gives the World Health Organisation’s definition of neonatal
mortality rate?
A The number of deaths during the first 28 completed days of life per 1000 live
births
B The number of deaths during the first 28 completed days of life per 100,000 live
births
C The number of deaths during the first 365 completed days of life per 1000 live
births
D The number of deaths during the first 365 completed days of life per 10,000 live
births
E The number of deaths, including stillborn fetuses of more than 24 weeks’
gestation, up to 28 completed days of life, per 1000 pregnancies
67. The quadruple test is a widely used screening test that aims to identify pregnancies
with a high-risk of chromosomal abnormalities.
Which of the following gives the best definition of the test’s specificity?
258 Chapter 15 Mock paper 1
A The proportion of women with a normal pregnancy who had a low-risk result
B The proportion of women with an affected fetus who had a high-risk result
C The proportion of women with a high-risk test result with an affected fetus
D The proportion of women with a low-risk test result with a normal pregnancy
E None of the above
68. The age of menarche was recorded for 100 women who attended a rapid access
gynaecology clinic with suspected ovarian cancer. The data obtained showed a
normal distribution.
The following values were obtained.
Mean = 13 years
Standard deviation = 2 years
What is the standard error of the mean for this sample?
A 0.1
B 0.2
C 0.5
D 1
E 2
69. A research study is designed to look at the association between mothers who
smoke during pregnancy and the subsequent growth of their children. The study
population is all babies born in the Daisy Maternity Unit between 1975 and 1980.
The babies were classified at birth as having being born to women who smoked
during their pregnancies or not. All of the children have their height and weight
measured every year from birth to the age of 20 years.
What study design is being used?
A Case-control study
B Cohort study
C Cross-sectional study
D Double-blinded study
E None of the above
73. A 28-year-old woman who is 13 weeks pregnant consents for routine antenatal
screening. The results of her quadruple test show the fetus has a 1 in 58 chance of
having trisomy 13.
What is trisomy 13 commonly known as?
A Cri-du-chat syndrome
B Down’s syndrome
C Edwards’ syndrome
D Patau’s syndrome
E Wolf–Hirschhorn syndrome
74. A 16-year-old boy is brought to his general practitioner by his parents. They are
concerned that he appears to have developed breast tissue. On questioning,
he feels self conscious about his appearance and feels his genitalia are smaller
than individuals of his own age. On examination, he appears tall for his age,
with objectively long arms and legs. Gynaecomastia is noted, alongside a fat
distribution typically seen in females.
What is the most likely genotype of this individual?
A 45 XO
B 46 XO
C 46 XX
D 46 XY
E 47 XXY
75. A 40 year old primiparous woman has an elevated risk of trisomy 21 (1 in 50) at
antenatal screening and opts for an amniocentesis at 15 weeks’ gestation. The fetus
is found to have the karyotype 46 XX/47 XX +21.
What may this karyotype indicate?
A Trisomy 21
B Turner’s syndrome
C Klinefelter’s syndrome
D Mosaic for Down’s syndrome
E None of above
76. A couple are seen for preconception counselling. The 26-year-old male partner
is of above average height, with noticeably long arms. He is being monitored
for worsening aortic root dissection and has had pleurodesis for recurrent
260 Chapter 15 Mock paper 1
pneumothoraces. His vision is mildly impaired due to optic lens subluxation. The
couple wishes to use preimplantation genetic screening techniques to prevent
their children from inheriting their father’s condition.
Which genetic condition does the male partner have?
A Congenital contractual arachnodactyly
B Ehlers–Danlos syndrome
C Klinefelter’s syndrome
D Marfan’s syndrome
E Triple X syndrome
78. Which of the following genetic conditions occurs as a result of genomic imprinting?
A Angelman’s syndrome
B Fragile-X syndrome
C Friedreich ataxia
D Patau’s syndrome
E All of the above
79. Which of the following hormones is not secreted by the human placenta?
A Human chorionic gonadotrophin
B Oestrogen
C Oxytocin
D Progesterone
E Relaxin
80. At a term delivery, there is some concern about the placental structure.
Which of the following statements about the umbilical cord is correct?
A At term the mean length is 70 cm
B It is formed at 8 weeks’ gestation
C 3% of cords have a single artery
D Umbilical arteries arise from the internal iliac artery
E Venous drainage is mainly to the inferior vena cava via the ductus arteriosus
81. Considering placental transport, which of the following are correctly paired?
A Active transport: amino acids
B Active transport: glucose
C Facilitated diffusion: free fatty acids
Questions: SBAs 261
84. Which of the following statements is correct in regard to the double Bohr effect?
A The fetal side becomes acidotic
B The fetus loses metabolites to the mother
C Maternal and fetal oxygen dissociation curves move towards each other
D The maternal oxygen dissociation curve shifts to the left
E The maternal side has an increased pH
86. A 21-year-old woman is seen in the gynaecology clinic complaining of pain in the
lower abdomen during the middle of her menstrual cycle.
A surge in which hormone around day 14 of the menstrual cycle leads to
ovulation?
A Follicle-stimulating hormone
B Luteinising hormone
C Oestradiol
D Progesterone
E Testosterone
262 Chapter 15 Mock paper 1
87. During oogenesis, at what point is the second meiotic division is completed?
A At ovulation
B Immediately prior to the formation of the secondary oocyte
C Immediately prior to the formation of the primary oocyte
D At fertilisation
E None of the above
88. Which of the following structures communicates with the umbilical vein to form
the ductus venosus?
A Aorta
B Inferior vena cava
C Left atrium
D Pulmonary artery
E Right atrium
89. Which of the following is a branch of the posterior division of the internal iliac artery?
A Inferior gluteal artery
B Internal pudendal artery
C Obturator artery
D Superior gluteal artery
E Uterine artery
90. After an elective caesarean section the anaesthetic team decide to administer a
transversus abdominis plane block to provide analgesia. They use ultrasound to
identify the layers of the abdominal wall.
Which of these muscles is innervated by the femoral nerve?
A External oblique
B Iliacus
C Internal oblique
D Rectus abdominis
E Transverse abdominis
Answers 263
Answers
1. A False
B True
C False
D True
E False
In the wall of the female pelvis the ureter forms part of the posterior boundary
of the ovarian fossa, in which the ovary is situated. From here, it runs medially
and anteriorly on the lateral side of the cervix and the upper part of the vagina to
reach the fundus of the bladder. Here it is accompanied by the uterine artery for
approximately 2.5 cm, which then crosses in front of the ureter and ascends between
the two layers of the broad ligament.
The labia minora are longitudinal cutaneous folds running obliquely downwards
from the clitoris, between the labia majora. They contain both sweat and sebaceous
follicles.
The internal anal sphincter is an involuntary smooth muscle which receives
parasympathetic supply from the inferior hypogastric plexus (S1, S2, S3) to maintain
resting tone. Sympathetic supply is excitatory.
2. A True
B False
C True
D True
E True
The ischiorectal fossa is a triangular space containing fat, found on either side of
the anal canal below the pelvic diaphragm. The levator ani forms the apex, with the
obturator internus muscle forming the lateral wall and the anal canal the medial
wall. The sacrotuberous ligament and the gluteus maximus are found posteriorly.
The perineal skin forms the base.
3. A False
B False
C True
D True
E True
The rectum is approximately 15 cm long and starts at the level of the third sacral
vertebra. It has an outer longitudinal and an inner circular layer of smooth muscle
and is lined by columnar epithelium.
264 Chapter 15 Mock paper 1
• Artery:
- upper two-thirds – superior rectal artery
- lower one-third – middle rectal artery
• Vein: superior rectal and middle rectal veins
• Nerve: inferior anal nerve
• Lymph: preaortic nodes, inferior mesenteric lymph nodes, pararectal nodes
4. A False
B True
C True
D True
E True
Nerve supply to the uterus is from the inferior hypogastric plexus which is derived
from the sympathetic supply T10–T11. The pain from the uterus passes in the inferior
hypogastric plexus, along with pain sensation from the superior region of the cervix.
Pain from the inferior region of the cervix is via the pelvic splanchnic nerves. The blood
supply to the uterus is from the uterine arteries and these arise from the anterior
division of the internal iliac arteries. The ureter passes beneath the uterine artery.
5. A True
B True
C False
D True
E True
The sacrum is composed of five fused vertebra which provide four foramina. The
innominate bone of the pelvis is made up of the ilium, ischium and pubis bones.
They all contribute to the acetabulum which accommodates the femoral head to
form the hip joint. The obturator foramen is closed by a fibrous membrane and is
created by the ischial ramus together with the pubic bone. The obturator foramen
contains the obturator artery, vein and nerve. The pubic symphysis is a cartilaginous
joint that connects the superior rami of both pubic bones.
6. A False
B True
C False
D False
E False
Boundaries of the femoral ring are:
• Anteriorly: inguinal ligament
• Posteriorly: pectineus
• Medially: lacunar ligament
• Laterally: femoral vein fascia
Answers 265
7. A True
B True
C False
D False
E False
Parathyroid hormone-related peptide (PTHrP) is a hormone, related to parathyroid
hormone (PTH). It may be secreted by some cancers, including breast and
squamous cell and is implicated in the hypercalcaemia of malignancy. It has a role
in endochondral bone development and regulates chondrocyte proliferation.
Being part of the PTH hormone family, PTHrP produces many of the same effects
of PTH. It does not cause raised calcitriol levels and concentration is normal in
hyperthyroidism.
8. A False
B False
C True
D True
E True
Second messengers are intracellular molecules that relay signals from receptor
proteins to intracellular receptors. The major types of second messenger systems are
(1) the cyclic nucleotides, i.e. cyclic adenosine monophosphate (cAMP) and cyclic
guanosine monophosphate (cGMP) (2) gases such nitric oxide and carbon monoxide
(3) calcium ions and (4) the phosphoinositol system, i.e. inositol triphosphate
and diacylglycerol. Second messengers are associated with increasing the signal
strength of the first messenger, i.e. the hormone, which is detected by its receptor,
and form part of a communication cascade. Acetylcholine is a neurotransmitter and
acts as a first messenger and utilises second messengers such as cAMP and inositol
triphosphate. Adenosine triphosphate is not a second messenger, but is a coenzyme
used in cell signalling; it is converted to the second messenger cAMP by the action
of adenylate cyclase.
9. A False
B True
C True
D False
E False
Uterine activity is dependent on the balance between the myometrial relaxants
and contractants. Oxytocin and prostaglandins – in particular prostaglandin F2α –
both contribute to myometrial contractility. They act by increasing the intracellular
calcium concentration via the action of phospholipase C and the subsequent
stimulation of myosin light chain kinase and calcium-dependent protein kinase. The
number of oxytocin receptors increases throughout pregnancy due to increased
266 Chapter 15 Mock paper 1
11. A False
B False
C True
D True
E False
Sperm entering the oocyte leads to completion of the second meiotic division.
Capacitation involves release of lytic enzymes as the outer acrosomal membrane
of the sperm fuses with cumulus cells of the ovum. It is thought that this process
is essential to the process of fertilisation. It also prevents further sperm from
penetrating the ovum. During the passage of the ovum from the ovary to the uterus,
there is a temporary halt of movement at the ampulla of the fallopian tube. Because
of this delay in motility, fertilisation often occurs at this location. Muscle activity of
the fallopian tube aids the movement of the fertilised egg, which enters the uterus 5
days after fertilisation
12. A True
B False
C False
D True
E True
Answers 267
Peptide hormones act through cell surface receptors which are divided into four
groups:
1. Seven-transmembrane domain
2. Single-transmembrane domain
3. Cytokine receptors
4. Guanylyl cyclase-linked receptors.
Seven-transmembrane receptors pass in and out of the cytoplasm, with a carboxy
terminus linked to the G-protein transducer and the amino terminus linked to
the hormone domain. The action of luteinising hormone and follicle-stimulating
hormone is via this receptor. The growth factor receptors are linked to tyrosine
kinase. Hormones acting through nuclear receptors include steroid and thyroid
hormones. Nuclear receptors are found in the cytoplasm or the nucleus itself.
Receptors in the cytoplasm include those for glucocorticoids and progesterone.
Receptors in the nucleus include those for oestrogens and vitamin-D.
16. A True
B False
C False
D False
E True
Vitamin D is a steroid hormone and is synthesised from cholesterol. Ninety per cent is
synthesised in the skin as a result of the action of UV light on 7-dehydrocholesterol to
form cholecalciferol. Ten per cent is absorbed in the diet. Both forms are transported
to the liver where they undergo 25-hydroxylation. From here it is stored in body fat
as calcidiol (25-hydroxyvitamin D). Alpha1-hydroxylation occurs in the kidney and is
tightly regulated by parathyroid hormone (Figure 15.1).
Skin Liver
↑ Parathyroid
7-dehydrocholesterol hormone secretion
25-hydroxychole-
Vitamin D calciferol (Vitamin D)
in food
↑ 1,25-dihydroxy-
cholecalciferol
Answers 269
17. A False
B True
C True
D True
E False
Although some data may have a normal distribution, if there are extremes of values
(also known as outliers) this may lead the distribution to be either negatively or
positively skewed. In positively skewed data the extremes of values are found
towards the right-hand of the distribution and the data can be described as
having a right-hand tail. In negatively skewed data the extremes of values are
found towards the left-hand of the distribution and the data distribution can be
described as having a left-hand tail. Skewed data may have a unimodal and a
bimodal distribution. In order to more easily analyse skewed data it can be partially
normalised by logarithmic transformation (Figure 15.2).
Bland JM, Altman D. Statistics notes: transforming data. BMJ 1996;312:770.
18. A True
B False
C True
D False
E False
270 Chapter 15 Mock paper 1
19. A False
B True
C False
D True
E True
Delay in conceiving is a common problem. Although the majority of couples will
conceive within 1 year of having regular unprotected sexual intercourse, up to 1
in 7 couples will seek help regarding fertility. Of those seeking assistance many
present with primary subfertility, i.e. the couple have never conceived a pregnancy.
Other couples will present with secondary subfertility, i.e. they have previously
conceived a pregnancy together, regardless of the outcome of the pregnancy
(either a live birth or a miscarriage). Following investigation, the cause of primary
subfertility is still unexplained for around 20% of couples. Male factors are attributed
to around 20–30% of cases of couples with primary subfertility. Ovulatory and
tubal dysfunctions are the other main contributors to subfertility. Around 8% of
the population require the assistance of reproductive techniques such as ovulation
induction, intrauterine insemination and in vitro fertilisation.
StratOG.net. Subfertility: Epidemiology, ethical and legal issues of subfertility. London: StratOG, 2012.
www.rcog.org.uk/stratog.
20. A False
B False
C True
D False
E True
The p-value refers to the probability of detecting a significant finding in a study if
the null hypothesis is true. The p-value assumes that the null hypothesis is true. The
standard p-value used in most statistical analyses is 0.05 (however, a p-value of 0.01
Answers 271
or lower could be used). If the resultant p-value obtained from a study is < 0.05 then
the null hypothesis can be rejected. That is, we can be 95% certain that the observed
effect did not occur due to chance alone. Another way of describing this outcome is
that the result was significant at the 5% level.
If, when using the same level of significance, the resultant p-value was greater
than or equal to 0.05 then the null hypothesis can be accepted; i.e. the result is not
significant at the 5% level. The inference here is that the effects observed in the
study may have occurred due to chance alone.
It is important to remember that the chosen p-value is not entirely robust. For
example, when a p-value of 0.05 is used 5% of the time the null hypothesis will be
rejected incorrectly. The p-value cannot indicate the likelihood of a type 1 error.
Sedgwick P. Statistical question: P values. BMJ 2010;340:c2203.
21. A True
B True
C True
D False
E True
Cystic fibrosis is an autosomal recessive condition, which can be caused by a
variety of different mutations affecting the CFTR gene found on chromosome 7.
Neurofibromatosis type 1 is caused by a mutation of the neurofibromin (NF) 1 gene
of chromosome 17. The gene is transmitted by autosomal dominant inheritance,
although in many cases the disease is caused by a random gene mutation.
Neurofibromatosis type 2 is caused by a mutation of the NF2 gene which is found on
chromosome 22.
Prader–Willi syndrome is caused by either a loss or mutation of genes found on
the proximal arm of chromosome 15. An example of genomic imprinting, it occurs
through the loss of the paternally derived genes as a consequence of either deletion
or due to maternal disomy of chromosome 15. Angelman syndrome is also example
of genomic imprinting and arises when there is loss of the maternal component of
chromosome 15. Sickle-cell disease is an autosomal recessive condition, caused by a
mutation in the beta-globulin gene found on chromosome 11. Duchenne muscular
dystrophy is X-linked recessive.
22. A False
B True
C False
D True
E False
Amniocentesis and chorionic villus sampling (CVS) are both invasive prenatal
diagnostic tests. They can be used to provide a diagnosis if there is thought to be a
raised risk of fetal abnormality. They are offered if there is a raised risk of aneuploidy
272 Chapter 15 Mock paper 1
23. A False
B True
C False
D True
E False
Tuberous sclerosis is an example of an autosomal dominant genetic disorder. In
autosomal dominant conditions, inheritance of a copy of the defective chromosome
leads to expression of the condition. Cystic fibrosis shows an autosomal recessive
mode of inheritance, by which both parents must carry a copy of the defective gene
for the condition to be expressed, with an estimated 1 in 4 offspring of two carriers
expressing the condition, 2 in 4 neither carriers affected and 1 in 4 an unaffected carrier.
Other autosomal recessive conditions include sickle-cell anaemia, β-thalassaemia and
Tay–Sachs disease. Fragile X is inherited by X-linked dominant inheritance. Duchenne’s
muscular dystrophy shows an X-linked recessive inheritance.
24. A False
B True
C False
D True
E True
A Barr body is found in all somatic cells in females. Each Barr body represents an
inactivated X chromosome. They may be stained and visualised at the periphery
of nuclei halted at interphase. Individuals with Turner’s syndrome typically have an
absence of one of the X chromosomes and therefore are missing a Barr body, rather
than having an additional copy. This monosomy is described as 45 X0.
25. A True
B True
C True
D True
E False
Answers 273
Females born with Turner’s syndrome typically have primary amenorrhoea due to the
presence of streak gonads and are unable to conceive. Some individuals do experience
menarche, but often experience an early menopause. Rarely, women with Turner’s
syndrome are able to conceive without assisted reproductive techniques (ART).
Individuals with Klinefelter’s syndrome may have varying degrees of hypogonadism
with associated low levels of testosterone and in some cases azoospermia. Androgen
therapy may be required manage hypothalamic – pituitary axis dysfunction.
Individuals with Klinefelter’s syndrome do rarely conceive without the need for ART.
Cystic fibrosis in males is associated with absence of the vas deferens thus leading
to azoospermic ejaculate. Women with cystic fibrosis may experience amenorrhoea
secondary to malnutrition. Both Klinefelter’s syndrome and mild forms of cystic
fibrosis may be diagnosed late in life when a couple have been unable to conceive.
Both males and females with Down’s syndrome may be able to conceive, however
fertility is often reduced.
26. A True
B True
C False
D False
E True
α-Thalassaemia is an autosomal recessive inherited haemoglobinopathy associated
with defective synthesis of α-globin chains. The severity of the disease depends
on how the number of genes for α-globin that are affected (four genes in total
code of α-globin). When only one gene has a deletion an individual is considered
an unaffected carrier. When two genes on a single chromosome (or a single gene
on two chromosomes) are affected, the individual can be considered to have
the α-thalassaemia trait. Those with the trait are typically unaffected, with some
individuals affected by mild anaemia. Haemoglobin H disease is caused by deletion
of three (of the four) α-globin genes. The minimal production of α chains leads to
the excessive formation of tetrameric β-globin chains which have a very high affinity
for oxygen and are therefore poor at delivering oxygen to tissues. Haemoglobin
H disease is associated with severe anaemia and splenomegaly. The deletion of all
four α-globin genes leads to formation of haemoglobin Bart’s (due excessive delta
tetramers) in the absence of any α-globin formation, with subsequent poor oxygen
delivery. Affected fetuses develop hydrops fetalis, with few surviving to delivery.
Advances in fetal medicine and in utero blood transfusion may lead to the survival of
individuals with a condition that until recently was thought to be incompatible with
life.
27. A False
B True
C False
D True
E False
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Fetal circulation involves high venous return from the placenta, maintaining a
right to left shunt through the foramen ovale. This enables oxygenated blood to
be delivered to the heart and brain. Oxygen saturation of the umbilical vein is
approximately 70–80%. Approximately 10% of blood from the pulmonary artery
travels to the lungs. Fetal haemoglobin (HbF) is comprised of two α chains and two
γ chains. HbF has a higher affinity for oxygen than adult haemoglobin. Ninety per
cent of fetal haemoglobin is HbF up until the third trimester, when it begins to be
replaced with adult haemoglobin.
Fetal red blood cells are larger than maternal cells, with a shorter life span and lower
levels of carbonic anhydrase and 2,3-diphosphoglyceric acid. They have no ABO
antigens until after birth.
28. A False
B True
C True
D False
E True
Creatinine is filtered by the kidneys with no tubular reabsorption. The levels of
creatinine in the blood and urine can be used to determine the creatinine clearance
rate which gives a value of glomerular filtration rate (GFR), a marker of renal function.
The creatinine levels in general reflect the individual’s muscle mass. Serum levels
of creatinine only tend to rise once there is a significant damage to the nephrons
and therefore creatinine is a poor indicator of early renal damage. In pregnancy,
creatinine levels tend to decrease and therefore an increase above normal values
may indicate significant renal dysfunction. Creatinine clearance is often a more
useful measurement of renal function and is calculated by comparing the amount of
creatinine in the urine and the blood, giving an overall indication of the GFR.
29. A False
B False
C True
D True
E True
The filtration fraction describes the ratio of the glomerular filtration to the renal
blood flow. It is usually about 20% and represents the volume of fluid reaching
the renal tubules. Filtration fraction of the kidneys only falls at the beginning
of pregnancy, with the amount of sodium filtered by the kidneys remaining
unchanged.
During pregnancy the kidneys do increase in size and generally increase in length by
approximately 1 cm. The ureters dilate as a result of the effect of progesterone and
the increasing weight of a gravid uterus.
Answers 275
The dilation of the ureters is one reason why urinary tract infections are increasingly
common in pregnancy and symptoms may be more subtle.
At term, both the renal blood flow and the glomerular filtration rate are significantly
increased, by up to 50%.
30. A False
B False
C True
D False
E True
Progesterone-only contraceptives are now widely used and may be taken in tablet
form, intradermally or as a levonorgestrel-releasing intrauterine system. Although
referred to as containing ‘progesterone’ they actually contain synthetic analogues
of progesterone and more accurately should be described as ‘progestogen-only
contraceptives’.
The usage of continuous progesterone analogues provides reliable contraception;
however, this success is not based on the reliable prevention of ovulation and
overall only around 60% of cycles will be anovulatory. Much of its effect comes
from increased viscosity of cervical mucus that is associated with high levels of
progesterone. Thick cervical mucus prevents passage of sperm and therefore
acts as a barrier to conception. These changes in cervical mucus last only for
around 20 hours after administration and therefore influence the need to take the
progesterone-only pill within a short time window, every 24 hours.
Under the influence of constantly raised levels of progesterone the endometrium
remains thin, further creating a hostile environment for any potential embryo
implantation. Unlike the combined oral pill, the uptake of this form of contraception
is not influenced by normal bowel flora so it is not affected by concomitant use of
antibiotics. As progesterone-only contraceptives do not contain oestrogens they are
not associated with any detrimental effects on breastfeeding.
Faculty of Sexual Health & Reproductive Healthcare, Royal College of Obstetricians and Gynaecologists.
Clinical Guidance: Progestogen-only Pills. London: FSRH, 2009.
31. C Pyramidalis
Pyramidalis is a triangular muscle which lies within the rectus sheath in front of the
rectus abdominis. It is absent in 20% of people and is supplied by the subcostal nerve.
The subcostal nerve is the anterior branch of the 12th thoracic nerve. It communicates
with the iliohypogastric nerve and gives a branch to pyramidalis. It gives off a lateral
cutaneous nerve supplying sensory innervation to the skin over the hip.
32. B Iliacus
Iliacus is separated from extraperitoneal tissue by the iliac fascia. It has a wide
peripheral attachment to the iliac crest which it shares with the psoas muscle and
276 Chapter 15 Mock paper 1
descends to leave the abdomen behind the inguinal ligament. The iliacus muscle
has innervation from the femoral nerve and lumbar plexus. The iliacus and psoas
muscles act in synergy to flex the hip joint.
36. E L2 and L3
The lateral cutaneous nerve of the thigh is a cutaneous nerve originating from the
lumbar plexus. It arises from the dorsal division of L2 and L3. It emerges laterally on
the psoas muscle and after crossing the iliacus muscle, passes under the inguinal
ligament and divides into anterior and posterior branches.
42. A
Above pectinate line: derived endoderm, superior
rectal artery
The pectinate line lies at the junction of the upper two-thirds and the lower
one-third of the anal canal. Embryologically this represents the junction of the
hindgut and the proctodeum (Table 15.1).
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43. A
Lateral wall of ischiorectal fossa; above
sacrotuberous ligament
The pudendal canal is a tunnel of fascia which runs in the lower lateral wall of the
ischiorectal fossa, just above the sacrotuberous ligament. It contains the pudendal
nerve and the internal pudendal vessels. During a pudendal block, the pudendal
nerve is infiltrated where it crosses the ischial spine. It is reached through the vagina
and infiltrated medial to the ischial spine.
45. B T7–T12
The rectus abdominis muscle originates at the pubis muscle and has its insertion
into the costal cartilages of the 5th, 6th and 7th ribs and the sternum. It is contained
within the rectus sheath which is made up of the aponeuroses of the external and
internal oblique muscle and the transversus abdominis muscle. The external oblique
is the most superficial aponeurosis to make up the rectus sheath and has the internal
oblique beneath it to keep it separate from the rectus muscle. It is supplied by the
inferior epigastric artery and has its nerve supply from the thoracoabdominal nerves,
T7–T12.
46. D Rickets
This 4-year-old boy is suffering from rickets, which is caused by failure or delay to
mineralise endochondral bone in the growth plate. The main cause is impaired
metabolism or deficiency of vitamin D. His mother is complaining of premenstrual
symptoms, combined with bony pain. These are symptoms of vitamin D deficiency
in adults. Treatment for both of these patients would be to ensure adequate sunlight
Answers 279
48. B Hyperglycaemia
A glucagonoma is a tumour of the α cells of the pancreas. It is associated with
excessive production of glucagon. Glucagon can be thought of as acting
in opposition to insulin, therefore raising serum glucose levels through
gluconeogenesis and lipolysis. This rare tumour is characterised by a state of
extreme hyperglycaemia due to excessive levels of glucagon. Other manifestations
include a characteristic rash and anaemia. Although incredibly rare, this tumour is
more common in perimenopausal and postmenopausal women.
49. D pH 7.50, pCO2 3.0 kPa, pO2 9.2 kPa, HCO3 25 mmol/L
This patient has an acute pulmonary embolus (PE). PE is a relatively common
postoperative complication and clinical presentation includes chest pain, dyspnoea
and haemoptysis. Signs and symptoms in this case are the acute dyspnoea and pain
on inspiration. The low oxygen saturations and tachycardia would also be found in
patients with acute PE. It usually occurs when thrombosis from a more distal vein
breaks loose and embolises into pulmonary blood vessels. The arterial blood gas
in a patient with a PE most commonly shows respiratory alkalosis. The low partial
pressure of carbon dioxide is most likely caused by hyperventilation. In cases of
massive PE, the infarcted or non-functioning areas of the lung may lead to increased
pCO2 values. Hypoxaemia occurs due to altered areas of perfusion and ventilation
of the lung tissue (VQ mismatch). Although a pH of 7.2 is reasonable, this patient is
extremely unlikely to have a pO2 of 12.0 kPa, given oxygen saturation of 93%.
280 Chapter 15 Mock paper 1
50. A
pH 7.16, pCO2 8.2 kPa, pO2 15.3 kPa, HCO3 21.2 mmol/L
This patient has central respiratory depression due to opiate overdose. Fatty liver
of pregnancy may be associated with an acid-base abnormality if it is severe.
Symptoms include fatigue, nausea and vomiting, and upper abdominal pain, usually
in the third trimester. The pattern on arterial blood gas usually shows a mixed
metabolic and respiratory acidosis, reflected in the degree of acidosis.
The Henderson–Hasselbach equation describes the relationship of pH as a measure
of acidity.
[A-]
pH = pKa + log
[HA]
Where pKa is the acid dissociation constant.
the ovum is moved medially by the action of cilia lining the tube and muscular
action. The ovum is halted at the fallopian ampulla for up to 36 hours and therefore
fertilisation occurs at this location most frequently.
55. D Prostate
The mesonephric duct ultimately gives rise to several parts of the male urogenital
tract, including the epididymis, the vas deferens and the seminal vesicle. The prostate
is not derived from the mesonephric duct and develops from the urogenital sinus.
56. D
Shortened Q–T interval and widened
T wave on ECG
Hypercalcaemia may cause ECG changes, specifically a shortened QT interval and
a widened T wave complex. Hypocalcaemia may lead to many classic signs and
symptoms, one of which is a prolonged Q–T interval on ECG. Circumoral tingling and
numbness, carpopedal spasm and depression are all symptoms of hypocalcaemia.
Chvostek’s sign may be positive, twitching of the face with tapping of the facial
nerve. Trousseau’s sign is a carpopedal spasm, which can be induced by inflating a
BP cuff around the arm. Calcium levels may be misinterpreted if the albumin levels
are abnormal and therefore calculation should always take this into account.
57. D 21α-hydroxylase
Congenital adrenal hyperplasia (CAH) is an autosomal recessive disorder which occurs
as a result of a defect in the pathway of steroidogenesis in the adrenal gland. As a
result of this, there is cortisol deficiency and increased androgen production. The
majority of cases occur as a result in deficiency of the enzyme 21α-hydroxylase. CAH
is rare and occurs in approximately 1 in 14,000 births. Presentation of this syndrome
may include salt wasting if production of aldosterone is affected and hypoglycaemia
may occur. Neonates may have ambiguous genitalia and, despite a 46 XX genotype,
may appear male. Diagnosis is made via detection of 17-hydroxyprogesterone levels.
It may also be necessary to perform a 24-hour urinary steroid analysis.
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58. D Phenytoin
Hirsutism is the presence of hair on the body and face that grows in excess. It is
usually in a male pattern of growth and is caused by an excess of testosterone. It is
associated with polycystic ovarian syndrome and alopecia.
The Ferriman–Gallwey score may be used to grade hirsutism and uses a score of 0–4
ranging from no hair cover (0) to fully hair covered (4) in 9 areas of the body: upper
lip, chest, chin, upper abdomen, lower abdomen, upper and lower back, upper arms
and thighs. A score above 8 suggests possible androgen excess.
Other drug causes include danazol, progesterones (including the combined oral
contraceptive pill), metoclopramide, methyldopa, anabolic steroids, reserpine,
testosterone, cyclosporine, minoxidil and diazoxide.
Hypothalamus
TRH
TSH
Thyroid gland
61. B Bicarbonate
Calcium is essential for the regulation of the nervous and musculoskeletal systems
and enzyme and hormone action. Calcium is an important intracellular messenger
which has an essential role in the maintenance of cell membrane potential of nerve
and cardiac cells and contractile muscle cells. It is absorbed by active transport in the
duodenum. Total body calcium is about 1–2 kg with 99% held in the skeleton, 1%
intracellular and 0.1% extracellular. Of the extracellular portion, approximately 55%
is in the bound form. Most of this calcium is bound to plasma proteins, the majority
of which is albumin. Extracellular calcium may also be bound to anions such as
phosphate, lactate and bicarbonate.
The remaining extracellular calcium is in the ionised form, which is biologically
active. The average level of calcium in plasma is 2.5 mmol/L, however levels range
from 2.2–2.6 mmol/L. A level of > 2.6 mmol/L, taking into account corrected levels,
would indicate a state of hypercalcaemia. In hypoalbuminaemia, there is less calcium
in the bound state and therefore a higher level of total calcium.
PTH action. Alpha1-hydroxylation of vitamin D takes place in the kidney and this is
enhanced by PTH action. PTH enhances the osteoclastic activity in bone, enhancing
bone resorption.
PTH acts on many organ systems:
• Bone: increases release of calcium, indirectly stimulates osteoclasts, increased
bone resorption.
• Kidney: enhances active reabsorption of calcium and magnesium from distal
tubules, increases excretion of phosphate
• Intestine: increases absorption of calcium by increasing production of
vitamin D.
66. A
The number of deaths during the first 28 completed
days of life per 1000 live births
The World Health Organisation defines the neonatal mortality rate as the number of
deaths during the first 28 completed days of life per 1000 live births in a given year
or period. It considers the neonatal period to begin at birth and to carry on until 28
completed days of life. The definition includes babies who have shown any sign of
life following delivery, even if this is only for a short period of time.
World Health Organization. Health Status Statistics: Mortality. Neonatal mortality rate (per 1000 live
births). http://www.who.int
Answers 285
67. A
The proportion of women with a normal pregnancy
who had a low-risk result
Specificity of any test refers to its ability to correctly identify those individuals
without any pathology so, in this case, it refers to the proportion of women who
had a normal pregnancy and were given a correct low-risk result at screening. The
specificity of a test should aim to be as high as possible, i.e. as close to 1 or 100% as
possible. Similarly the sensitivity of a test should aim to be as close to 1 or 100% as
possible. The sensitivity of a test refers its ability to correctly identify affected/high
risk individuals. For this test it is the proportion of women with an affected fetus who
were given a high-risk result at screening.
68. B 0.2
The standard error of the mean (SEM) is a measure of how close the sample mean
lies from the mean of the true population. The larger the sample size (n), the smaller
the SEM. Further, the smaller the resultant SEM, the more accurate an estimate the
sample mean is of the true population mean. The SEM can be calculated using only
the sample size and the standard deviation.
SEM = Standard deviation ÷
Standard deviation = 2, n = 100
SEM = 2 ÷ = 2 ÷ 10 = 0.2
A type 2 error (also known as a β error) is actually more common than a type 1 error
and is said to have occurred when the null hypothesis has been accepted when
there is, in fact, a difference between the sample groups being looked at.
71. D
Community-acquired Group A
streptococcal disease
The 8th report of the Confidential Enquiries into Maternal Deaths in the United
Kingdom classified causes of maternal mortality as directly related, indirectly related
or unrelated to pregnancy. Directly related causes of maternal mortality are those
that result from obstetric complications. In the options A to E, the only cause directly
related to pregnancy is community-acquired group A streptococcal disease. Genital
tract sepsis, predominantly due to group A streptococcal disease, was given as the
leading direct cause of maternal death in the report, and its incidence had increased
since the previous triennial report. Causes of death that are indirectly related to
pregnancy are those that are not caused by obstetric complications but were made
worse by the physiological changes associated with pregnancy. These indirectly
related causes may include conditions that were pre-existing or were diagnosed
during pregnancy.
Within the UK, suicide is included as one of the indirectly related causes of maternal
death because it is usually the result of puerperal psychosis. Other indirect causes
include cardiac disease, diabetes and hormone-dependent cancers.
Centre for Maternal and Child Enquiries (CMACE). Saving Mothers’ Lives: reviewing maternal deaths to
make motherhood safer: 2006–2008. The Eighth Report on Confidential Enquiries into Maternal Deaths in
the United Kingdom. BJOG 2011;118:1–203.
72. B
The median is the middle value in
ranked set of data
The median is one of the terms used to describe an ‘average’ of a set of data. The
median is the middle value in a ranked data set. It should not be confused with
the mode which refers to the most frequently occurring value in a data set. It also
differs from the mean which is calculated by dividing the sum of a data set by the
number of values in the data set. An advantage of using the median is that it is not
influenced by outliers or skewed data, which can affect the mean of a data set. The
median figure in a data set may be higher or lower than the mean.
74. E 47 XXY
This boy has Klinefelter’s syndrome, which is a relatively common disorder of the
sex chromosomes. Around 1 in every 1000 male babies born have Klinefelter’s
syndrome. Affected individuals typically have the genotype 47 XXY, indicating
that they have an extra X chromosome. This extra chromosome is present due a
non-disjunction event in either spermatogenesis or oogenesis. Physical features
associated with Klinefelter’s syndrome include above average height, long arms
and legs, gynaecomastia, a female body fat distribution and varying development
of secondary sexual characteristics. Undiagnosed individuals typically present
due to concern regarding gynaecomastia or unexplained infertility. Historically,
individuals with Klinefelter’s syndrome have been described as experiencing higher
levels of behavioural difficulties and having lower IQs than average, although these
stereotypes are probably unjustified.
deformities of the chest wall. This individual has known aortic root dilation, a
common finding in many affected individuals. Other cardiac sequelae include aortic
dissection and mitral valve prolapse.
Congenital contractual arachnodactyly is an autosomal dominant condition causing
skeletal abnormalities as a consequence of a mutation of the protein fibrillin-2.
Ehlers–Danlos syndrome refers to heterogenous group of disorders associated with
defects in collagen synthesis, the classical form of which is an autosomal dominant
inherited condition.
79. C Oxytocin
As well as transporting molecules between the mother and the fetus, the placenta
functions as an important endocrine organ during pregnancy. It synthesises and
secretes many hormones which function to maintain and support the pregnancy.
Answers 289
82. E Vasodilation
Oestrogen exerts a series of effects, both at local and systemic levels. Oestrogen
promotes vascular tone, leading to vasodilation, with both rapid and chronic
effect. There are two oestrogen receptors: α and β. The α-receptor is found on the
290 Chapter 15 Mock paper 1
endothelial cell membrane and directly activates nitric oxide. Oestrogen is involved
in other systemic changes, e.g. it helps maintain bone density levels, increases
clotting and decreases cholesterol and low-density lipoprotein levels. Other
properties include protection against atherosclerosis.
87. D At fertilisation
Oogenesis is the process where an ovum is formed in females from primordial
germ cells. The primordial germ cells develop in the fetal gonadal tissue which
eventually becomes the fetal ovary. Here these primordial germ cells become
oogonia. The oogonia undergo division by mitosis, rapidly increasing in number
to form several million oogonia by the second trimester of fetal life. Oogonia then
become primary oocytes through mitosis. Surrounded by primordial follicles
the primary oocytes are diploid; they begin meiosis 1 during the third trimester
of pregnancy, and this is arrested at prophase. They remain in this state until
ovulation many years later. At ovulation, meiosis 1 recommences leading to the
production of the secondary oocyte and the first polar body. The secondary
oocyte is haploid and immediately after meiosis 1 is completed enters meiosis 2.
This second meiotic division becomes halted at metaphase II. The second meiotic
division, leading to the production of a mature ovum and the second polar body, is
only completed should fertilisation occur.
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Artery Organ
Iliolumbar Muscles of posterior abdominal walls, i.e.
quadrates lumborum, iliacus and psoas major
Cauda equina
Lateral sacral arteries (superior and inferior) Piriformis, erector spinae, sacral canal
Superior gluteal Gluteus minimus
Gluteus maximus
Gluteus medius
Tensor fascia lata
Piriformis
90. B Iliacus
The iliacus muscle does not form part of the anterior abdominal wall and is
innervated by the femoral nerve.
The anterior abdominal wall provides support for the internal structures. The
muscles of the anterior abdominal wall are:
• Rectus abdominis – from costal cartilages to the pubic crest
• Pyramidalis – may be absent (1 in 5 individuals), lies anterior to lower fibres of
rectus abdominis
• External oblique – runs downwards and forwards from large insertion from lower
8th ribs
• Internal oblique – runs opposite to the external oblique, upwards and forwards
from anterior iliac crest and inguinal ligament
Chapter 16
Mock paper 2
The 30 multiple choice questions and 60 single best answers presented in this
chapter should be worked through under exam conditions, and completed in two
and a half hours.
Questions: MCQs
Answer each stem ‘True’ or ‘False’.
1. Heparin:
A Low-molecular weight heparin has a shorter half-life than unfractionated heparin
B Action is measured using the activated partial thromboplastin time
C Is reversed with protamine
D Can cause bleeding in the fetus
E Can cause hypoaldosteronism
3. Danazol:
A Is used as a treatment for endometriosis
B Is a gonadotrophin agonist
C Can cause osteoporosis
D Inhibits ovarian steroidogenesis
E Can cause clitoral hypertrophy
C Rotate
D Slide
E Tilt and tip
9. Laparoscopic injuries:
A Serious complications occur in 1 in 1000 cases
B Usually occur before visualisation of the peritoneal cavity
C It is easier to diagnose bowel injury than bladder injury
D Intra-abdominal pressures of 5–10 mmHg should be used for gas insufflation
for insertion of the primary trochar
E Direct trochar insertion is an acceptable technique
19. The following are risk factors for the transmission of Group B streptococcal
infection to the neonate:
A Artificial rupture of membranes
B Birth prior to 37 weeks’ gestation
C Fetal blood sampling
D Instrumental delivery
E Rupture of membranes for longer than 12 hours
28. The following tumour markers are associated with these tumours:
A CA-125: ovarian cancer
B Carcinoembryonic antigen: breast cancer
C CA 19-9: pancreatic cancer
D Human chorionic gonadotropin: testicular seminomas
E Alpha-fetoprotein: colorectal cancer
29. Sarcomas:
A Are tumours of the connective tissue
B Contain spindle cells on microscopy
C Are benign tumours
D Are formed from mesenchymal tissue
E Kaposi’s sarcoma is a form of sarcoma
Questions: SBAs
For each question, select the single most appropriate answer from the five options
listed.
32. A 32-year-old woman is para one and is seen in the antenatal clinic at 36 weeks’
gestation to discuss the mode of delivery. Her last labour ended in an emergency
caesarean section at 8 cm dilatation for a fetal bradycardia. You are counselling
her about the risks of vaginal birth after caesarean section (VBAC).
What risk of uterine rupture should be quoted to patients when counselling
about VBAC?
A 1 in 100
B 1 in 200
C 1 in 500
D 1 in 1000
E 1 in 2000
33. A 28-year-old multiparous woman attends for a dating scan in early pregnancy.
She is unsure of the first day of her last menstrual period and reports that her
periods are irregular. Fetal heart activity is detected on the transvaginal scan.
What is the earliest gestation that fetal heart action can be detected on a
transvaginal ultrasound scan?
A 3–4 weeks
B 4–5 weeks
C 5–6 weeks
D 6–7 weeks
E 7–8 weeks
D QT interval
E T wave
35. A 33-year-old woman with known HIV is seen in a genitourinary clinic. She has
not commenced antiretroviral therapy. She describes deep dyspareunia, bilateral
pelvic pain and increased vaginal discharge. She is otherwise well and is apyrexial.
Serum inflammatory markers are normal. She is treated for suspected pelvic
inflammatory disease.
What is the most appropriate treatment?
A An extended course of oral antibiotics for 1 month
B Initiation of antiretrovirals
C Inpatient treatment for intravenous antibiotics
D Standard 2 weeks of antibiotic treatment
E None of the above
37. A 32-year-old woman presents with a 7-year history of painful periods, and a
3-year history of primary subfertility. Her serum follicular-stimulating hormone
level is 6.8 IU/mL and luteinising hormone is 6.7 IU/mL. Pelvic ultrasound was
unremarkable and her partner's semen analysis was normal.
What is the most appropriate investigation in this woman?
A Laparoscopy and dye test
B Brain MRI to exclude a prolactinoma
C Postcoital test
D Serum anti-müllerian hormone levels
E Serum testosterone level
38. A 40-year-old woman at 28 weeks’ gestation presents to the delivery suit with a
4-hour history of absent fetal movements and abdominal pain. On examination,
she is pale and has a hard tender abdomen. There is no fetal heart audible.
What is the most appropriate immediate plan of management?
A Administer corticosteroids
B Category one caesarean section
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39. A 41-year-old grand multiparous woman has a vaginal delivery. The midwife
reports that she felt dizzy and has now collapsed in a pool of blood while walking
to the toilet.
What is the most appropriate initial management?
A Call for immediate help
B Cannulate the patient and send blood for a cross match
C Ensure her placenta is complete
D Prescribe 40 IU oxytocin over 4 hours
E Catheterise the patient as her bladder is palpable
43. A 33-year-old woman attends the gynaecology clinic for investigation of her
recurrent first trimester miscarriages. A thrombophilia screen has been performed
as part of routine investigation.
Which of the following positive results would most likely suggest an acquired
thrombophilia, rather than an inherited one?
A Activated protein C resistance
B Anticardiolipin antibodies
C Antithrombin III deficiency
D Protein C deficiency
E Protein S deficiency
44. A 32-year-old woman attends for a review at 28 weeks’ gestation. She complains
of a circular rash on her legs and mild shortness of breath. Chest X-ray reveals
bilateral hilar lymphadenopathy. Her blood tests show a mildly elevated serum
angiotensin-converting enzyme level.
What is the most likely diagnosis?
A Crohn’s disease
B Polyarteritis nodosa
C Sarcoidosis
D Tuberculosis
E Wegener’s granulomatosis
45. A multiparous woman is in spontaneous labour at 40 weeks’ gestation. She has had
one previous caesarean section. She is being continuously monitored in labour
using cardiotocography (CTG). Her midwife is concerned that the CTG shows
reduced beat-to-beat variability.
Regarding CTG analysis, what is considered the normal range for beat-to-beat
variability?
A 1–5 beats per minute
B 2–8 beats per minute
C 5–10 beats per minute
D 5–15 beats per minute
E 10–25 beats per minute
46. A 23-year-old woman attends her 16 week antenatal appointment. Her booking
blood tests for hepatitis serology are as follows:
304 Chapter 16 Mock paper 2
HBsAg Positive
Anti-HBc Positive
Anti-HBs Negative
Anti-HBc IgM Negative
What is the patient’s most likely hepatitis B status?
A Acutely infected
B Chronically infected
C Previous immunisation
D Resolving acute infection
E Susceptible to hepatitis B infection
47. A 29-year-old hirsute woman attends the gynaecology outpatient clinic. She has
oligomenorrhea and secondary subfertility. Her ultrasound scan shows ovaries
with multiple peripheral cysts.
What is her anti-Müllerian hormone profile most likely to be?
A Undetectable
B 3.7 pmol/L
C 10 pmol/L
D 17.3 pmol/L
E 65 pmol/L
48. A nulliparous woman has an early pregnancy ultrasound scan and her serum
human chorionic gonadotropin (hCG) level taken as part of a study looking at the
correlation between gestational age and serum hCG levels. The scan shows a single
ongoing intrauterine pregnancy at 7 weeks’ gestation.
Which is the most likely serum hCG level to correspond with this pregnancy?
A 5000 IU/L
B 300,000 IU/L
C 120 IU/L
D 50 IU/L
E 300 IU/L
49. Type III hypersensitivity reactions occur in which of the following conditions?
A Goodpasture syndrome
B Multiple sclerosis
C Rheumatoid arthritis
D Streptococcal nephritis
E Tuberculosis
50. Which of the following immunoglobulin isotopes crosses the placenta to give the
fetus passive immunity?
A IgA
B IgD
Questions: SBAs 305
C IgE
D IgG
E IgM
53. A 35-year-old nulliparous woman is 14 weeks pregnant. She has recently arrived in
the United Kingdom from a South American country. She is under the care of the
infectious diseases team who are concerned she has yaws.
Which of the following is the cause of yaws?
A Treponema pallidum carateum
B Treponema pallidum endemicum
C Treponema pallidum pallidum
D Treponema pallidum pertenue
E Treponema paraluis cuniculi
54. A 25-year-old nulliparous woman is being seen in a fetal medicine clinic following
the detection of hydrops fetalis at a routine anomaly scan. Following investigation
primary maternal cytomegalovirus infection is suspected.
Which of the options below gives the genome structure for cytomegalovirus
(CMV)?
A dsDNA
B ssDNA
C dsRNA
D dsDNA-RT
E ssRNA-RT
56. A 26-year-old woman undergoes a grade one emergency caesarean section for
fetal bradycardia. She has diabetes and is obese. Ten days after the operation, she
is readmitted with a wound infection. The wound is erythematous and discharging
pus. There were no intraoperative complications.
What is the most likely operative factor contributing to the infection?
A Length of operation
B Presence of foreign material at operative site
C Sterilisation of instruments
D Surgical technique
E Underlying medical disorder
57. A 19-year-old woman has attended her local genitourinary medicine clinic for a
sexual health screening. Routine vaginal and endocervical swabs are taken and
show the presence of a Gram-negative bacterium. A diagnosis of N. gonorrhoeae
is made. The presence of which bacterial cell component is detected by the Gram
stain?
A Glycocalyx
B Mycolic acid
C N-acetyl glucosamine
D N-acetyl muramic acid
E Peptidoglycan
58. A woman attends the emergency department with severe left iliac fossa pain and a
small amount of vaginal bleeding. On examination, her abdomen is distended with
guarding and rebound tenderness. A urine pregnancy test is positive. An urgent
transvaginal scan shows a left tubal ectopic pregnancy.
Which of the following is a recognised risk factor for ectopic pregnancy?
A Combined oral contraceptive pill usage
B Multiparity
C Obesity
D Smoking
E Young maternal age
Questions: SBAs 307
65. Which of the following hormones is secreted by the acidophils of the anterior
pituitary gland?
A Adrenocorticotrophic hormone
B Follicle-stimulating hormone
C Growth hormone
D Oxytocin
E Thyroid-stimulating hormone
68. Which of the following is a recognised risk factor for the development of
cervical cancer?
A Early menarche
B Higher socioeconomic status
C Late age of first sexual intercourse
D Having a male partner who has been circumcised
E Use of the oral contraceptive pill
69. A 56-year-old woman attends the gynaecology outpatient clinic with a history of
postmenopausal bleeding. A pelvic ultrasound shows an endometrial thickness of
6 mm. Following an endometrial Pipelle biopsy and an MRI, a diagnosis of stage 1a
endometrial cancer is made.
Questions: SBAs 309
Which of the following is a risk factor for the development of endometrial cancer?
A History of endometriosis
B Multiparity
C Non-hormonal intrauterine device (IUD) usage
D Obesity
E Premature menopause
70. A 27-year-old woman has a smear test as part of the UK screening programme.
Following an abnormal result she attends a colposcopy clinic. On colposcopy, the
whitened appearance of her cervix on application of acetic acid is suggestive of a
human papilloma virus (HPV) infection.
Which of the following HPV subtypes is high-risk for the development of cervical
intraepithelial neoplasia?
A HPV 2
B HPV 6
C HPV 11
D HPV 16
E HPV 63
72. A 42-year-old woman delivers a baby at term weighing 2.5 kg. The baby is found to
have abnormalities including chondrodysplasia and hypoplasia of the nasal bridge.
Which medication is most likely to have caused these abnormalities?
A Azathioprine
B Chloramphenicol
C Gentamicin
D Sodium valproate
E Warfarin
76. A 19-year-old woman who is 28 weeks pregnant requests treatment for acne and is
prescribed an antibiotic by her general practitioner (GP). She goes on to deliver a
healthy baby girl at term. Two years later her daughter is noted to have unusually
grey teeth.
Which treatment for acne did her GP prescribed for acne?
A Chloramphenicol
B Cefalexin
C Co-trimoxazole
D Erythromycin
E Oxytetracycline
C Levetiracetam
D Phenytoin
E Sodium valproate
79. A 21-year-old woman presents to the emergency department with vaginal spotting
and lower abdominal pain. She has a positive pregnancy test and serum human
chorionic gonadotrophin is 2562 IU/L. She is found to have evidence of a left tubal
ectopic pregnancy on pelvic ultrasound scan. After counselling she chooses to
have medical treatment for the ectopic pregnancy.
Which is the most appropriate treatment?
A Methotrexate 75 mg IM once
B Methotrexate 5 mg PO daily for 14 days
C Mifepristone 600 mg PO once
D Misoprostol 400 µg PO once
E No treatment
83. Which of the following ovarian tumours is responsible for the majority of ovarian
malignancies?
A Brenner’s tumour
B Dermoid cyst
C Ovarian fibroma
D Serous cystadenocarcinoma
E Sertoli–Leydig cell tumour
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86. Which of the following is the most common form of cervical cancer?
A Adenocarcinoma
B Adenosquamous carcinoma
C Clear cell carcinoma
D Squamous cell carcinoma
E Villoglandular adenocarcinoma
88. A 72-year-old woman has a sudden onset loss of speech and hemiparesis. On
arrival in hospital her symptoms and neurological examination is suggestive of
a cerebrovascular incident. Subsequent imaging supports the diagnosis of an
ischaemic stroke, affecting her left cerebral hemisphere.
Which of the following forms of tissue necrosis is associated with her loss of
function?
A Caseous necrosis
B Coagulative necrosis
C Colliquative necrosis
D Fat necrosis
E Gangrenous necrosis
Answers
1. A False
B True
C True
D False
E True
Low-molecular weight heparin (LMWH) has a longer half life than unfractionated
heparins with more predictable effects, allowing for less frequent dosing. The action
of unfractionated heparin is monitored using the activated partial thromboplastin
time (APTT). The APTT is a measure of both the intrinsic and common coagulation
pathways.
2. A False
B True
C True
D True
E False
There are two drugs, commonly used in obstetric practice, which do not cross the
placenta into the fetal circulation: heparin and insulin.
Pethidine is 50% protein bound and is nearly totally freely diffusible across the
placenta. Maximum fetal uptake occurs approximately 2 hours after administration.
The rate of transfer across the placental membrane is dependent on factors including
thickness of the membrane, the diffusion coefficient and the area of diffusion.
Factors affecting transfer include:
• Lipid solubility: lipophilic molecules transfer more readily
• Ionisation: non-ionised molecules transfer
• pH: pH of maternal blood affects the degree of ionisation of drug
• Protein binding: unbound fraction diffuses
• Molecular weight: smaller molecules diffuse more easily
3. A True
B False
C False
D True
E True
Danazol is a derivative of ethisterone which is a form of modified testosterone.
Originally used for the treatment of endometriosis it is also used to treat
menorrhagia, fibrocystic breast disease and hereditary angioedema. Danazol
Answers 315
6. A False
B False
C True
D True
E False
Magnetic resonance imaging (MRI) is a modality which uses magnetic fields and
non-ionising radiation to induce movement of atomic nuclei (specifically protons)
within tissues. The excitation and subsequent relaxation of these protons can be
recorded and used to produce images. The Tesla is the international system unit used
to denote magnetic field strength. Absolute contraindications to MRI include cardiac
pacemakers, intracerebral aneurysm clips and automatic defibrillators. Relative
contraindications to MRI include pregnancy, cochlear implants and prosthetic heart
valves. T1-weighted images show tissues containing water and fluid as dark, whereas
fat appears bright. In T2-weighted images tissues containing water and fluid appear
as bright, and fat and bone appear dark.
7. A True
B False
C False
D False
E True
Dual energy X-ray absorptiometry (DEXA) is used to assess bone density.
DEXA uses two beams of X-rays, each with varying levels of radiation, which are
directed over bone. Bone mineral density (BMD) is calculated by subtracting soft
tissue absorption from the beam that is passed through the bone. The results of the
bone mineral density calculation can be used to give the patient a bone density
Z and T score. The T score compares the patient’s bone density to that of young
person with a normal bone mass. A T score of more than –1 is normal, a score of –1
to –2.5 is suggestive of osteopenia, whereas a score of less than –2.5 is required for
a diagnosis of osteoporosis. The Z score provides a measure of bone density using
age-matching by comparing the patient’s BMD with that of other individuals of the
same sex and same age.
8. A True
B True
C False
D True
E True
Placenta praevia is the partial or complete insertion of the placenta into the
lower segment of the uterus. It is associated with an increased risk of antepartum
haemorrhage, which can be life-threatening. It is usually diagnosed on ultrasound
Answers 317
and is present in around 0.5% of term pregnancies. Risk factors for the occurrence of
placenta praevia include previous caesarean section, assisted conception, multiple
pregnancy, uterine structural anomalies and smoking.
Royal College of Obstetricians and Gynaecologists. Placenta praevia, Placenta Praevia Accreta and Vasa
Praevia: Diagnosis and Management. Green-top Guideline 27. London: RCOG, 2011.
9. A True
B True
C False
D False
E True
Laparoscopic surgery is now widely used, with around 1 in 1000 cases being
associated with serious complications. The risk of injury is highest before the
peritoneal cavity has been clearly visualised. Recognised entry techniques
include the closed entry technique using a Veress needle that is widely practised
in gynaecological surgery and also the open Hasson technique which is more
commonly used by general surgeons. Palmer’s point entry may also be used. The
Hasson technique involves direct insertion of a blunt-ended trochar. This technique
can be used in very thin or obese women or those with multiple previous surgical
scars. Intra abdominal pressures of 20–25 mmHg should be obtained using gas
insufflation prior to insertion of the primary trochar. This can then be reduced to
allow easier ventilation of the patient. See Figure 16.1 for images of female pelvis
obtained using laparoscopy.
Royal College of Obstetricians and Gynaecologists. Preventing entry related gynaecological laparoscopic
injuries. Green-top Guideline 49. London: RCOG, 2008.
10. A True
B True
C True
D True
E True
318 Chapter 16 Mock paper 2
12. A True
B True
C False
D False
E True
Polycystic ovary syndrome (PCOS) is a common endocrine condition affecting
women which may lead to anovulatory subfertility. The Rotterdam criteria for
diagnosing PCOS are:
• Irregular or absent ovulation
• Clinical or biochemical signs of hyperandrogenism
• Polycystic ovaries on ultrasound (Figure 16.2)
Answers 319
Parvovirus B19 is a single stranded DNA virus which is most commonly found in
children, when it is known as slapped cheek syndrome. Up to 60% of the adult
population are thought to be immune to parvovirus B19, having formed IgG
antibodies from a previous infection. The incubation period is between 4 and 20
days, with the infectious period being from 5–10 days after the exposure to just
before the onset of the rash. Parvovirus B19 affects rapidly dividing cells, especially
erythroblasts. This can lead to severe anaemia in the fetus and hydrops fetalis.
Diagnosis is confirmed by identifying the presence of IgM antibodies to the virus,
even though the person infected with the virus may be asymptomatic. In the
presence of hydrops fetalis, parvovirus should always be investigated.
15. A False
B True
C False
D False
E True
Type I hypersensitivity reactions are the most common and potentially life-
threatening of the hypersensitivity reactions. Immunoglobin E (IgE) antibodies
are produced as a result of previous contact with the antigen. The sensitisation
process occurs through CD4+ Th2 cells, inducing class switching of antigen specific
B cells. When exposure reoccurs, the allergenic substance becomes bound to IgE
antibodies which are already bound to mast cells. This binding causes the mast
cells to degranulate with the rapid release of histamine. The release of histamine
is associated with systemic effects such as the contraction of smooth muscle
(by acting on H1 receptors), including that of the bronchi, leading to breathing
difficulties.
16. A False
B False
C True
D True
E False
Human leucocyte antigen (HLA) is another term for the major histocompatibility
complex (MHC). The MHC is located on the cell surface and presents protein chains
(peptides or antigens) to T cells. MHC class I molecules are expressed on the surface
of all nucleated cells, whereas MHC class II molecules are present only on specialised
antigen-presenting cells. The MHC class I molecule presents CD8+ T cells with
endogenous (cytoplasmically derived) antigen in the form of a short protein chain,
for example a peptide from an intracellular virus. It is made up of a heavy chain and a
β2-microglobulin. HLAs of the MHC class II type present CD4+ T cells with exogenous
antigens (derived from intracellular vesicles).
17. A True
B False
Answers 321
C False
D True
E True
Cytokines are small molecules that act as signals between cells. The different types
of cytokines are listed below:
• Interferons: inhibit viral replication
• Lymphokines: IL-2 made by T cells, IL-4 produced by Th2 cells and mast cells
• Monokines: IL-1, IL-6, IL-8, IL-12 and tumour necrosis factor-α
• Chemokines: activate and direct appropriate cells to sites of tissue damage or
trauma
18. A True
B True
C False
D True
E True
Actinomyces israelii is a Gram-positive anaerobic rod-shaped non-sporing
bacterium which is a commensal of the colon, mouth and vagina. It is the
commonest cause of actinomycosis, a chronic, suppurative and granulomatous
inflammatory infection. The presence of sulphur granules is characteristic
of actinomyces infection. The majority of cases of actinomycosis affect the
cervicofacial area, classically presenting as painless facial lumps; however thoracic,
abdominal and pelvic forms do rarely occur. Pelvic infection may be associated
with long-term usage of an intrauterine contraceptive device. Treatment of
actinomycosis requires a long course of penicillin.
19. A False
B True
C False
D False
E False
In addition to the incidental finding of maternal vaginal carriage of Group B
streptococcal (GBS) a series of risk factors have been identified which increase
the likelihood of transmission to the fetus as it makes its way through the birth
canal. These risk factors include prolonged rupture of membranes of more than
18 hours, maternal pyrexia in labour of >38°C and gestation of < 37 weeks.
The current RCOG guidance advises that routine administration of antibiotics
when these risk factors are present is appropriate. Having had a child previously
affected by neonatal GBS disease is also an indication for antibiotic therapy;
however, the known carriage of GBS in a previous pregnancy is not an indication
for administration.
322 Chapter 16 Mock paper 2
Royal College of Obstetricians and Gynaecologists. Prevention of Early Onset Group B Streptococcal
Disease. Green-top Guideline 36. London: RCOG, 2003.
20. A True
B False
C True
D True
E False
Necrotising fasciitis is an infection of subcutaneous tissue and may be caused
by either group A streptococcal infection (type 2 necrotising fasciitis) or by the
colonisation of a series of bacteria including Enterobacter species, streptococci and
staphylococci (type 1 necrotising fasciitis). Toxic shock syndrome may be caused
by the exotoxins released by Group A Streptococcus (Streptococcus pyogenes)
and Staphylococcus aureus; it may occur as a sequelae of necrotising fasciitis.
The mainstay of the medical emergency is immediate resuscitation, surgical
debridement of the affected tissue and the speedy administration of intravenous
broad-spectrum antimicrobials.
21. A True
B True
C False
D True
E False
The main types of human herpesviruses are:
• Herpes simplex virus type I and type II
• Epstein–Barr virus
• Cytomegalovirus
• Varicella zoster virus
Herpes type I and type II viruses have double-stranded DNA. Cytomegalovirus
rarely causes diseases unless patients are immunocompromised. About half of
the population has antibodies to this virus without ever having had symptoms.
Epstein–Barr virus infection is very common, with most of the population having
been exposed by adulthood.
Parvovirus B19 is a single-stranded DNA virus. Hepatitis B virus contains double-
stranded DNA and replicates using reverse transcriptase. Hepatitis A, C and E all have
the positive-sense, single-stranded RNA genome.
HIV is lentivirus, and a member of the retrovirus family, with a single-stranded RNA
genome.
22. A True
B False
C False
Answers 323
D True
E False
Fetal varicella syndrome (FVS) is caused by reactivation of the varicella zoster virus
(VZV) in utero. FVS is associated with a series of fetal abnormalities such as limb
hypoplasia and microcephaly and dermatomal skin scarring. Amniocentesis is not
used for diagnosis as the risk of infection is low even in the presence of VZV DNA in
the amniotic fluid.
Royal College of Obstetricians and Gynaecologists. Chickenpox in Pregnancy. Green-top Guideline 13.
London: RCOG, 2007.
23. A False
B True
C True
D False
E False
Rubella virus is a single stranded RNA togavirus. It is spread by droplet transmission
and is not treatable by antivirals. It is a live, attenuated vaccine and is therefore
not suitable to be given during pregnancy. If no immunity is found at the first
midwife (booking) appointment, vaccination should be offered after birth, prior to
leaving hospital. The prevalence of rubella is low in the UK due to the vaccination
programme. African countries, India and Pakistan have a prevalence rate of up
to 17%. Congenital defects follow rubella infection which has occurred during
the first 16 weeks of pregnancy; after that it point does not seem to cause fetal
abnormalities. The main defects associated with infection are cataracts, deafness,
and cardiac abnormalities. Maternal rubella can also increase the risk of miscarriage
and stillbirths.
Health Protection Agency. Guidance on Viral Rash in Pregnancy: Investigation, Diagnosis and
Management of Viral Illness Rash, or Exposure to Viral Rash Illness, in Pregnancy. London: HPA, 2011.
24. A False
B True
C True
D False
E True
The presence of an imperforate hymen is often diagnosed in teenage girls presenting
with amenorrhoae and abdominal pain. The hymen develops from the urogenital
sinus and by menarche the central portion is open. An imperforate hymen acts as a
solid membrane between proximal uterovaginal tract and the introitus. An imperforate
hymen is surgically easily resolved. It does not have a familial inheritance.
Balen AH, Creighton SM, Davies MC, MacDougall J, Stanhope R. Paediatric and Adolescent Gynecology: A
Multidisciplinary Approach. Cambridge: Cambridge University Press, 2004.
324 Chapter 16 Mock paper 2
25. A True
B False
C True
D False
E False
Placenta accreta is a relatively rare condition occurring in approximately 1 in 2500
pregnancies and complicates 5–10% of cases of placenta praevia. It is defined as
the invasion of the placental chorionic villi into the myometrium and predisposes
to postpartum haemorrhage (PPH). Causes of placenta accreta include Asherman’s
syndrome, as well as previous caesarean section and increased maternal age. It is
difficult to diagnose antenatally, however it may cause antepartum bleeding.
Royal College of Obstetricians and Gynaecologists. Placenta Praevia, Placenta Praevia Accreta and Vasa
Praevia: Diagnosis and Management. Green-top Guideline 27. London: RCOG, 2011.
26. A False
B True
C True
D True
E True
The presence of a single umbilical artery is associated with congenital abnormality in
30% of cases, including renal, musculoskeletal and cardiac conditions. It also has an
association with maternal diabetes and epilepsy. In patients with a single umbilical
artery, there are usually two vessels present: one artery and one vein, instead of the
usual two arteries.
Cunningham FG, Leveno KJ, Bloom SL, Hauth JC, Rouse DJ, Spong CY. William's Obstetrics, 23rd edn.
MacGraw-Hill, 2010.
27. A False
B True
C True
D False
E False
Atrophic vaginitis is a common condition in postmenopausal women. It is caused
by reduced oestrogen levels, which leads to a change in tissue composition
of the vaginal wall. These changes include a proliferation of connective tissue
and hyalinisation of collagen. Symptoms include dryness, itchiness and urinary
symptoms. Treatment usually consists of replacing the deficient oestrogen with
topical preparations.
Chapter 16: Genital Tract Infections. In: Collins S, Arulkumaran S, Hayes K, et al. Oxford Handbook of
Obstetrics and Gynaecology, 2nd edn. Oxford: Oxford University Press, 2010: 521.
Answers 325
28. A True
B False
C True
D True
E False
Tumour markers are often useful in the monitoring of cancers; however, as they
may also be raised in numerous non-malignant conditions, they should be used
cautiously in the diagnosis of malignancy.
29. A True
B True
C False
D True
E False
Sarcomas are malignant tumours of connective tissues, i.e. bone, muscle and
cartilage. These mesenchymal tumours form from tissue that was originally
embryonic mesoderm. They are highly vascular tumours, which grow quickly and
can metastasise via the bloodstream to the lungs and other sites. On microscopy
they consist of spindle cells. Sarcomas may be treated using radiotherapy,
chemotherapy or surgical excision. Patients with conditions such as Li–Fraumeni
syndrome, neurofibromatosis and carriers of the retinoblastoma gene have a higher
likelihood of developing sarcomas. Kaposi’s sarcoma is not, in fact, a form of sarcoma
but is actually a cancer of lymphatic endothelium which is associated with human
herpesvirus 8 and is also considered an AIDs-defining illness.
National Institute for Health and Clinical Excellence. Improving Outcomes for People with Sarcoma: The
Manual. London: NICE, 2006.
30. A True
B False
C True
D False
E True
Umbilical cord prolapse is the descent of the cord past the presenting part of the
fetus, when the membranes are no longer intact. Cord prolapse is an obstetric
emergency with a high rate of perinatal mortality, predominantly due to fetal
asphyxia. Many of the risk factors for cord prolapse are related to common
interventions and therefore can be pre-empted. These include artificial rupture
of membranes, external cephalic version, stabilising inductions of labour and
vaginal manipulation of the presenting part after membranes have ruptured, either
artificially or spontaneously. Risk factors relating to the mother or pregnancy itself
include multi-parity, prematurity, low birth weight, polyhydramnios, unstable or
326 Chapter 16 Mock paper 2
abnormal lie, an unengaged presenting part and prior to the delivery of a second
twin.
On recognition of umbilical cord prolapse, delivery should be expedited by
emergency grade one Caesarean section if delivery is not imminent vaginally.
Royal College of Obstetricians and Gynaecologists. Umbilical Cord Prolapse. Green-top Guideline 50.
London: RCOG, 2008.
32. B 1 in 200
Women who have undergone delivery by previous caesarean section need adequate
counselling early in the antenatal period in order to ensure that the subsequent
delivery proceeds safely. Women who have had a previous uncomplicated lower
segment caesarean section at term are usually able to be offered a vaginal birth after
a caesarean (VBAC), providing there are no contraindications to a vaginal delivery.
One specific risk that women should be counselled about is the risk of uterine
rupture through the previous scar. This is frequently quoted as 1 in 200 and it should
be explained to women that this is one of the reasons for continuous monitoring via
cardiotocograph. Other risks for patients undergoing VBAC include a 1% additional
risk of requiring a blood transfusion, increased risk of endometritis and increased
Answers 327
36. D
Referral to a genitourinary physician for
treatment in line with her condition
If a woman presents with primary genital herpes during her pregnancy she should
be referred to a genitourinary unit. She is likely to need antivirals such as acyclovir in
oral or intravenous form, depending on the severity of her symptoms.
328 Chapter 16 Mock paper 2
As there is the risk of vertical transmission at delivery, any woman who presents
towards the end of her pregnancy (within 6 weeks of likely delivery) needs
investigation to establish whether there is primary or secondary infection. Type-
specific herpes simplex virus antibody testing differentiates between primary and
secondary herpes. Detection of IgG antibodies matching those from genital swabs
confirms secondary herpes.
Caesarean section is the recommended mode of delivery for women who have
primary genital herpes confirmed within 6 weeks of their anticipated delivery date.
Women with recurrent genital herpes infection should not routinely be offered a
caesarean section as there is a much smaller risk of vertical transmission.
Royal College of Obstetricians and Gynaecologists. Management of Genital Herpes in Pregnancy.
Green-top Guideline 30. London: RCOG, 2007.
haemorrhage (PPH) initiated. The causes of PPH are often referred to as the four Ts;
Tone, Trauma, Tissue and Thrombin (Table 16.1).
Royal College of Obstetricians and Gynaecologists. Prevention and management of postpartum
haemorrhage. Green-top Guideline 52. London: RCOG, 2009.
44. C Sarcoidosis
Sarcoidosis is a granulomatous disease that affects many body systems. The
granulomata are non-caseating, unlike in tuberculosis. It mainly affects adults
Answers 331
47. E 65 pmol/L
Hirsutism is characterised by coarse hairs with a male-like distribution. It may affect
up to 15% of women. Polycystic ovary syndrome (PCOS) is the most common cause
of hirsutism. This patient’s hormone profile is suggestive of PCOS. Her anti-müllerian
hormone level is raised, both of which are consistent with this diagnosis.
It can be difficult to make a diagnosis of PCOS and therefore the Rotterdam criteria are
used once other causes have been excluded. The Rotterdam criteria make a diagnosis
on the basis of the presence at least two out of three of features of (1) polycystic
332 Chapter 16 Mock paper 2
48. A 5000 IU/L
In early pregnancy, an expert transvaginal ultrasound combined with serum human
chorionic gonadotropin (hCG) have a very high positive predictive for diagnosing an
ectopic pregnancy. A singleton intrauterine pregnancy should be visible with hCG
from 1000–2400 IU/L. Multiple pregnancies may be visible with higher hCG values.
The diagnosis of ectopic pregnancy should be based on the identification of an
extrauterine sac and indirect signs such as a complex adnexal mass or free fluid.
Progesterone levels >25 nmol/L are likely to indicate, and
>60 nmol/L are strongly
associated with, pregnancies subsequently shown to be intrauterine, although
a small proportion of ectopic pregnancies have been reported with a serum
progesterone concentration of >60 nmol/L.
Sagili H, Mohamed K. Pregnancy of unknown location: an evidence-based approach to management . The
Obstetrician & Gynaecologist 2008; 10:224–230.
50. D IgG
Immunoglobin (IgG) is the most plentiful of the immunoglobulin isotopes and is
fundamental to the secondary immune response. It is also the only form of antibody
that is able to cross the placenta and by doing so confers the growing fetus with
passive immunity. Maternal IgA is found in large quantities in breast milk and
therefore confers passive immunity to the newborn. The immune system of the
fetus starts to develop early on in the first trimester and includes the production of
complement and the antibody IgM. IgA has been detected in fetal serum during the
third trimester.
51. C Opsonisation
The complement system forms part of both the innate and acquired immune
systems. The complement proteins produced by the liver are activated in the form
of a cascade, via three different pathways (classical, alternative and lectin). The
different products of each stage of the complement cascade have different roles.
Opsonisation is one of the major functions of the complement system. Complement
proteins cover the surfaces of pathogens, such as bacteria, which then attract
cells such as macrophages, which phagocytose the pathogen. The complement
protein C3b is the main protein involved in opsonisation. Other functions of the
complement system include cell lysis, chemotaxis, increasing vascular permeability
by stimulating histamine release and activation of the lipoxygenase pathway.
54. A dsDNA
Cytomegalovirus, also known as human herpesvirus 5, belongs to the herpes
family of viruses and its genome consists of double-stranded DNA. The majority of
adults will have been exposed to the virus and are seropositive if tested. Concern
regarding the timing of exposure occurs during pregnancy, as fetal infection may
be associated with an array of defects including microcephaly, hepatitis, cerebral
palsy and sensorineural hearing loss. The answer stems given for this question derive
from the Baltimore classification system. The system classifies viruses according
to their genome, i.e. whether their nucleic acid is RNA or DNA, whether they are
double-stranded (ds) or single-stranded (ss), their sense (+ or –) and whether their
replication uses reverse transcriptase (RT).
Health Protection Agency. Guidance on Viral Rash in Pregnancy: Investigation, Diagnosis and
Management of Viral Illness Rash, or Exposure to Viral Rash Illness, in Pregnancy. London: HPA, 2011. www.
hpa.org.uk
57. E Peptidoglycan
Gram-staining detects the presence of peptidoglycan in bacterial cell walls. The Gram-
stain is therefore used to differentiate between Gram-positive and Gram-negative
bacteria and it is the composition of the cell wall which gives them these properties.
Gram-positive bacteria have a thicker peptidoglycan layer than Gram-negative bacteria.
Gram-positive bacteria stain blue/black; Gram-negative stain pink/red. The bacterial
cell wall is made up of N-acetyl glucosamine and N-acetyl muramic acid linked to
peptidoglycan. It is this lipid, sugar and polypeptide structure which is responsible
for maintaining the rigidity of the cell wall. The presence of a slimy glycocalyx on the
surface of the bacteria is protective against destruction, e.g. by antimicrobials. Mycolic
acid is found in high concentrations in the cell walls of organisms that are classified as
‘acid-fast’, such as Mycoplasma.
58. D Smoking
An ectopic pregnancy is a pregnancy that occurs when the embryo implants outside
the uterine cavity. The most common site for an ectopic pregnancy is within the
fallopian tubes; however, they may also occur in the ovaries, the cornua of the
uterus, the cervix and rarely the abdominal cavity. Smoking is known to have an
association with ectopic pregnancy, however obesity is not a recognised risk factor.
Any form of previous pelvic surgery raises the risk of a subsequent ectopic
pregnancy, e.g. appendicectomy, due to the occurrence of adhesions. Other
risk factors include pelvic inflammatory disease (genital infection), previous
ectopic pregnancy, tubal surgery, endometriosis, use of the coil and usage of the
progesterone-only contraceptive pill.
blood flow is slowed with the subsequent development of stasis. Angiogenesis and
fibrosis occur as part of chronic inflammation.
60. C Testicles
Choriocarcinoma is classified as both a form of gestational trophoblastic disease
and also as a form of primary germ cell tumour. Rarely choriocarcinoma can be
found as a germ cell tumour in the testicles and in the ovaries. When present in
the testes choriocarcinoma is classified as an non-seminomatous germ cell tumour
and is known to be the most aggressive and rapidly metastasising form of this
type of tumour. More commonly, choriocarcinoma is described as a malignancy
of trophoblastic cells and usually occurs following the development of a partial
or complete molar pregnancy, although it can occur after normal pregnancy,
ectopic pregnancy or following termination of pregnancy. This form of tumour
macroscopically has a fleshy appearance, whereas microscopically there is an
abundance of cytotrophoblasts and syncytiotrophoblasts with an absence of
chorionic villi. Typically there is also evidence of haemorrhage.
62. C Hyperchromatism
The histological term dysplasia is used to describe abnormal changes, both
architectural and cytological, in the development of a cell type.
Dysplasia is characterised by the following:
• Anisocytosis: cells of varying size
• Hyperchromatism: excessive pigmentation due to abnormal chromatin
• Poikilocytosis: abnormally shaped cells
• Presence of mitotic figures: indicative of high cell turnover
• Loss of cell orientation
Dysplasia typically occurs in response to an environmental stimulus, e.g. the
dysplastic changes seen in Barrett’s oesophagus occur in response to chronic
exposure to stomach acid. These changes may be an indicator of malignant
potential, but they may be reversible. The cervical intraepithelial neoplasia (CIN)
grading system refers to the severity of dysplastic changes in the cervix, where CIN I
refers to mild dysplasia, CIN II to moderate dysplasia and CIN III severe dysplasia.
Answers 337
63. E
Pregnancy-induced idiopathic
thrombocytopaenic purpura
In haemolytic anaemia there is premature destruction of red cells, together with the
reduced lifespan of circulating red cells. In pregnancy this form of anaemia may be
caused by pre-eclampsia, haemolysis, elevated liver enzymes, low platelet count
syndrome, haemolytic uraemic syndrome (HUS) and disseminated intravascular
coagulopathy.
Chronic idiopathic thrombocytopaenic purpura (ITP) is a platelet disorder, not
a haemolytic disorder. It caused by the development of IgG autoantibodies
to platelets. It may be secondary to a variety of conditions such as systemic
lupus erythematosus (SLE) and HIV. The condition manifests with peripheral
thrombocytopaenia, however examination of the bone marrow may reveal the
presence of megakaryocytes.
Primary ITP is a diagnosis of exclusion and can only be made after secondary causes
have been excluded. Treatment is supportive and may include the administration of
corticosteroids.
Thrombotic thrombocytopaenic purpura (TTP) shares similarities with HUS, and
in both conditions there is microvascular platelet aggregation. In HUS there is
predominantly renal involvement. HUS typically presents in the postnatal period.
Polymorphic eruption of pregnancy (PEP) is an itchy erythematous rash that has no
known cause, although it usually occurs during a first pregnancy. The distinguishing
feature is sparing of the umbilical region and both PEP and gestational diabetes are
not associated with microangiopathic haemolytic anaemia.
67. A Erythroplakia
Premalignant diseases are conditions that, if untreated, have a high likelihood
of becoming malignant. Erythroplakia (and leukoplakia) are both precancerous
conditions of the oropharynx. Other examples of premalignant conditions
include Crohn’s disease, ulcerative colitis and Barrett’s oesophagus where there is
chronic inflammation leading to increased risk of bowel and oesophageal cancers
respectively. Actinic keratosis, if left untreated, may develop into squamous cell
carcinoma. Cervical intraepithelial neoplasia has the potential to change into
cervical cancer if not monitored and appropriately treated. Lichen sclerosus is
not a premalignant condition, however it thought around 5% of women with the
condition go on to develop vulval cancer. Neither lichen planus nor herpes simplex
infection are associated with the subsequent development of malignant conditions.
69. D Obesity
The incidence of endometrial cancer in United Kingdom is around 20 per
100,000 women, the majority of which are postmenopausal. The combined oral
contraceptive, especially in users of more than 10 years, halves the risk of this form
of cancer. Endometrial hyperplasia is recognised as being a premalignant condition.
Simple hyperplasia is likely to be treated with progesterone. Atypical hyperplasia
on the other hand may indicate that cancer is already present on other parts of
the uterus and, if not, will lead to endometrial cancer in 30% of cases. Invasion
of endometrial cancer is local, through the myometrium and into the peritoneal
cavity. An MRI is performed to assess the extent of myometrial invasion and stage
the disease. Stage 1a and 1b disease is treated by performing a total abdominal
hysterectomy (TAH) and bilateral oophorectomy (BSO). Stage 1c and 2a disease are
treated by TAH and BSO, followed by radiotherapy. Risk factors for the disease are
related to high levels of oestrogen (i.e. obesity) or many menses, i.e. nulliparous
women and those of who have had a late menopause.
70. D HPV 16
Human papilloma virus (HPV) is a double-stranded DNA virus. There are many
subtypes of the virus, 30 of which are present in the human genital tract. Most lead
to focal epithelial proliferation. High-risk virus types commonly detected in women
with CIN II and CIN III are HPV16, HPV18 and HPV31. However, the prevalence of HPV
in sexually active women under 30 years old is as high as 40%, but most will clear
it within 6–8 months. Being older and smoking decreases the chance of the virus
being cleared. HPV2 and 63 are associated with the presence of common warts.
HPV6 and 11 are commonly associated with anogenital warts.
71. D µ
There are three main opioid receptors: µ, δ and κ. It is now widely accepted that
most of the analgesic effects of opioids are achieved through the µ receptor. All
opioid receptors are G-protein coupled receptors and act through the inhibition
of adenylate cyclase. Action at these receptors also leads to opening of potassium
channels causing hyperpolarisation. There is also inhibition of release of
neurotransmitter via inhibition of calcium release at the calcium channels. Other
effects of opioids include dysphoria (κ receptor), reduced gastrointestinal motility
(all receptors), respiratory depression (µ and δ receptor) and physical dependence (µ
and κ receptor).
72. E Warfarin
Warfarin, a coumarin, is a teratogen and should be avoided during pregnancy.
Alternative therapy with a low-molecular weight heparin is more appropriate in
women who require anticoagulation during pregnancy.
The most teratogenic effects occur if given during the first trimester and can lead
to fetal warfarin syndrome. Warfarin given in the second and third trimesters is
thought to be associated with a lower level of birth defects. Fetal warfarin syndrome,
340 Chapter 16 Mock paper 2
74. E Thiopental
To reduce the risk of gastric aspiration, rapid sequence induction with cricoid
pressure is used for these women. To minimize the placental transfer of anaesthetic
agent to the fetus, catheterisation, cleaning and draping should be performed prior
to administration of anaesthetic in order that the surgeon can begin the procedure
immediately. Intravenous anaesthetic agents:
• Thiopental: barbiturate, very high lipid solubility
• Etomidate: involuntary movements during induction
• Propofol: rapidly metabolised and recovery with no hangover, used especially for
day-case surgery
• Ketamine: causes profound analgesia, blocks NMDA receptor
• Midazolam: benzodiazepine, used for preoperative sedation.
76. E Oxytetracycline
Tetracyclines, such as doxycycline and oxytetracycline, are broad-spectrum
bacteriostatic antibiotics giving them a wide variety of uses, including the treatment
of acne. They are known to chelate calcium leading to tetracycline deposition in
growing teeth and bone. Given in the second and third trimester of pregnancy may
cause maternal hepatotoxicity and fetal teeth discolouration in addition to skeletal
deformities. These effects can also theoretically occur with breastfeeding, although it
has been speculated that the calcium in milk may help prevent teeth discolouration.
Because of these risks all tetracyclines should be avoided in pregnant women, those
breastfeeding and in children under the age of 12 years.
77. E Ramipril
Ramipril is an angiotensin-converting enzyme (ACE) inhibitor and is used for the
treatment of conditions such as hypertension and heart failure. They act on the
renin–angiotensin–aldosterone system, preventing the conversion of angiotensin I to
angiotensin II and therefore reduce arterial pressure and cardiac load. Unfortunately
the use of ACE inhibitors in pregnancy, particularly in the first trimester, is associated
with problems such as fetal skull defects, cardiovascular malformation, fetal
renal problems and oligohydramnios. Alternatives treatments for hypertension
in pregnancy include labetalol, a first line treatment choice and nifedipine and
methyldopa as a second-line therapy.
Cunningham FG, Leveno KJ, Bloom SL et al (eds). William' s Obstetrics, 23rd edn. The MacGraw-Hill, 2010.
inhibits folate reductase. Current RCOG guidance advises that the administering a
single 75 mg intramuscular injection of methotrexate is a suitable treatment for ectopic
pregnancy in cases where β-human chorionic gonadotropin (β-hCG) is < 3000 IU/mL.
Mifepristone and misoprostol both have a role in termination of pregnancy and the
medical management of miscarriage but are not suitable for the management of tubal
ectopic pregnancy.
Royal College of Obstetrics and Gynaecology. The Management of Tubal Pregnancy. Green-top Guideline
24. London: RCOG, 2010.
81. B
It acts in the renal tubule to reduce phosphate
reabsorption
Calcitonin is an amino acid that is synthesised by the parafollicular cells of the
thyroid gland. Parafollicular cells are neuroendocrine in origin and are derived from
the neural crest. These neuroendocrine cells make up only 0.2% of the total thyroid
gland cells. Calcitonin is regulated by circulating levels of calcium. When there are
high levels of calcium, the level of calcitonin increases and vice versa. The primary
organ of action is in the bone where it reduces the activity of osteoclasts. In the renal
tubules, calcitonin acts to reduce the reabsorption of phosphate and calcium.
84. C 10%
Teratomas are germ cell tumours of the ovary. They are typically benign, occurring
in women under the age of 30 years. Only 10% of teratomas are bilateral. They rarely
rupture and in most cases patients are asymptomatic, however up to 10% result in
torsion and patients may present with an acute abdomen. They are mostly unilocular
and thin-walled. The vast majority of ovarian teratomas are mature and cystic and
are known as dermoid cysts. They usually measure < 20 cm.
85. E Osteosarcoma
Osteosarcomas are the most common malignant primary bone tumour and are a
form of mesenchymal tumour. Most commonly they are found at the metaphysis of
long bones. Chondromas are benign tumours of hyaline cartilage. Haemangiomas
are not a type of bone tumour and actually describe benign tumours characterised
by blood vessels filled with blood. They are typically seen in infancy and often
spontaneously resolve. Fibromas are benign tumours of fibrous connective tissue.
Osteoid osteomas are small benign bone tumours that are most commonly arise in
young adults.
rare forms of cervical cancer include neuroendocrine tumours. By far the majority of
cervical cancers are caused by HPV infection. Unfortunately some cervical tumour
types are less effectively detected by national screening programmes and typically
present at a more advanced stage, e.g. adenocarcinomas and neuroendocrine
tumours.
87. D Koilocytosis
Cervical intraepithelial neoplasia (CIN) is a premalignant condition that if left
untreated has the potential to become cervical cancer. CIN is divided into three
grades depending on the epithelial depth of the dysplastic changes occurring in the
cells of the transformation zone of the cervix.
CIN is caused by chronic human papillomavirus infection, predominantly virus types
16 and 18. Liquid cytology now provides the method used for screening for CIN in
the UK.
Cytological changes characteristic of CIN of dysplasia include poikilocytosis
(abnormally shaped cells), an increased nuclear:cytoplasmic ratio, nuclear
hyperchromasia, multinucleated cells and evidence of increased mitoses, suggesting
a high cell turnover.
Koilocytosis refers to presence of cells infected with HPV which have abnormally
large and irregularly shaped nuclei. See Table 16.4 for classification of CIN.
A Anal canal 13–14, 277, 278 Bacterial vaginosis (BV) 197, 333
Android pelvis 17, 21 Barr body 272
Abdominal aorta 20, 20, 24, 25
Aneuploidy 106 Barrett’s oesophagus 217
Abdominal wall
Angelman syndrome 105, 105, Bartholin’s glands 16
anterior 293
271, 288 Basophils 224
posterior 19
Angiotensin-converting enzyme Beat-to-beat variability 331
Acetylcholine 265
(ACE) 119 Bejel 197, 333
Acetyl coenzyme A (acetyl-CoA)
Angiotensin-converting enzyme β-human chorionic gonadotrophin
35, 36, 41
inhibitor 119, 341 (β-hCG) 168–169, 171
Acoustic impedance 142
Angiotensin II 66, 119 β-naphthylamine 216
Actinic keratosis 217, 338
Aniline dye 216 Bicornuate uterus 223
Actinomyces israelii 199, 321
Ankle oedema 329 Bilateral oophorectomy (BSO) 339
Actinomycosis 199, 321
Anthropoid pelvis 21 Bilirubin 124
Activated partial thromboplastin
Antibodies see Immunoglobin Bioavailability 236
time (APTT) 314
(IgG) Biophysical profiling 139–140, 158
Activated protein C resistance 330
Anticardiolipin antibodies 330 Bipolar diathermy 138
Active transport 284
Anticoagulation, in pregnancy243 Bladder cancer 216
Acute tubular necrosis (ATN) 225
Anticonvulsant therapy 244 Bleomycin 240
Addison’s disease 66–67, 80
Antidiuretic hormone (ADH) Bloom’s syndrome 218
Adenocarcinoma of prostate 217
79–80, 128 Bohr effect 290
Adenohypophysis 338 see also
Antiepileptic drugs (AEDs) 341 Bone, disorders of 40
Pituitary gland
Antimetabolites 315 Bone metastases 283
Adenosine 237
Antiphospholipid syndrome 330, Bone mineral density (BMD) 316
Adenosine triphosphate 265
345 Bony pelvis 26, 26
Adrenal function, in pregnancy 75
Aortic arch chemoreceptors 124, Bradykinin 237
Adrenal glands 17–18, 22
126 BRCA1 38, 107–108
Adrenaline 81
Apoptosis 37–38, 220 Breech presentation 223
Adrenocorticotrophic hormone
Arachidonic acid 36–37 Brenner tumours 343
(ACTH) 66, 79
Arthus reaction 181 Broad ligament 277
Aldosterone 218
Asherman’s syndrome 154 Bromocriptine 123
Alimentary system, embryonic
Aspirin 241, 243
49, 50
Assisted reproductive techniques
Alkaline phosphatase (ALP) 120 C
(ART) 273
Alpha-fetoprotein (AFP) 106, 107,
Atosiban 122 C3, 181
173
Atrophic gastritis 217 CA 15-3, 173
21α-hydroxylase 281
Atrophic vaginitis 324 Cabergoline therapy 123, 342
Alpha-thalassaemia 109, 273, 288
Atrophy 222 Caesarean section 152
Amenorrhoea 155
Attenuated vaccines 183–184 Calcitonin 342
Amitriptyline 241
Autosomal dominant inheritance Calcium 283
Amniocentesis 107, 271–272
107–108, 108 Calcium homeostasis 75,
Amniotic fluid 49–50
In pregnancy 284
Amniotic fluid index (AFI)
Candida albicans 244
139–140, 175 B Capacitation 50, 266
Anaesthetic agents
Bacteria, classification of 194 Carbamazepine 241
inhalational 238
Bacterial toxins 198, 198 Carboprost 243
intravenous 340
348 Index
Ehlers–Danlos syndrome 288 Femoral sheath 19 Glassy cell carcinomas of cervix 343
Eicosanoids 36–37 Femoral triangle 18, 22, 23 Glomerular capillary endotheliosis
Electrocardiogram (ECG) 122, 138, Ferriman–Gallwey score 282, 332 224
141, 327 Fertilisation 266 Glucagon 81
Electronic fetal monitoring 170 site of 280–281 Glucagonoma 279
Electrosurgery 138 Fertility, assessment and Glucokinase 34–35
Elimination of drugs 236 management of 328 Glutamate 237
Embryonic development, early 48 Fetal blood sample (FBS) 167, 169, Gluteus maximus 22
Embryonic foregut 24 169, 171–172 Glycogen 35
Enalapril 119 Fetal circulation 274 Glycolysis 34, 34–35, 40
Endometrial cancer 172, 216–217, Fetal haemoglobin (HbF) 274, 291 overall product of 40
339 Fetal heart action 327 rate-limiting step of 40
Endometrial hyperplasia 158 Fetal hydrops 137 Glycosuria 126
Endometriosis 154 Fetal varicella syndrome (FVS) 323 Gonadotrophin-releasing hormone
Endometritis 203–204 Fetal warfarin syndrome 339–340 (GnRH) 69
Endometrium 277 Fetal well-being, assessment of Gonads, development of 51
Endotoxins 198, 198 158 Gonorrhoea 149, 195
Enflurane 238 Fibromas 343 Goodpasture syndrome 332
Enzyme inducers 236 Filtration fraction 274 G protein-coupled receptors
Enzyme inhibitors 236–237 Fisher’s exact test 92 (GPCRs) 39
Episiotomy 158 Flavin adenine dinucleotide Gram-negative bacteria 194, 335
Epithelial surface damage, (FADH2) 35 Gram-positive bacteria 194, 335
radiotherapy and 140 Fluorescent treponemal antibody– Graves’ disease 65, 283
Epstein–Barr virus 197, 201, 216, absorption (FTA–abs) test 334 Group B β-haemolytic
322 Fluorouracil 240, 315 Streptococcus (GBS) 195, 321
Ergometrine 122, 243 Folic acid supplementation 244 infection in infants 195
Erythromycin 243 Follicle-stimulating hormone (FSH) transmission to fetus, risk
Erythroplakia 338 69, 70, 71, 82 factors for 321
Escherichia coli 200–201, 229 Foramen ovale 292 Growth factor receptors 268
Essential amino acids, and non- Fossa ovalis 292 Growth hormone (GH) 76
essential amino acids 40–41, 41 Fragile-X syndrome 104, 288 Guthrie test 38
Estimated glomerular filtration rate Friedreich ataxia 288 Gynaecoid pelvis 21
(eGFR) 125
Ethambutol 203
Etomidate 340 G H
Exomphalos 137 Ganciclovir 198 Haemangiomas 343
Exotoxins 198, 198, 200 Gangrenous necrosis 345 Haemoglobin H disease 273
Expiratory reserve volume 131 Gardnerella vaginalis 333 Haemolytic anaemia 337
External oblique muscle 276 Gas gangrene 200 Haemolytic disease of newborn
Extraembryonic endoderm 51 Gastrointestinal stromal tumours 182, 221
(GISTs) 217 Haemophilia A 221
Gaussian distribution, normal 91, Haemophilia B 221
F 92 Haemorrhagic shock 229
Factor V Leiden 157, 221 G-banding 103 Halothane 238
Familial Down’s syndrome Genital herpes, in pregnancy Hansen’s disease 199
108–109 327–328 Headache, in pregnancy 318
Fanconi’s anaemia 218 Genital tract sepsis 286 Henderson–Hasselbach equation
Fat metabolism 36 Genomic imprinting 271, 288 280
Fat necrosis 345 Gentamicin 243 Heparin 314, 340
Fat soluble drugs 236 Germ cell layers 50–51, 51 Heparin-induced thrombocytopaenia
Fatty liver of pregnancy 280 Gestational diabetes mellitus (HIT) 345
Female urethra 17 (GDM) 168 Heparin therapy 243
Femoral nerve 13 Gestational trophoblastic disease after delivery 157
Femoral ring 264 223–224 side effects 242
350 Index
Parvovirus B19 201, 320, 322 Plasma protein A (PAPP-A), Puberty, in female 70
Patau’s syndrome 105, 286–287, pregnancy-associated 107 Pubic symphysis 264
288 Plasminogen activator inhibitor Pubococcygeus 21
Patent ductus arteriosus (PDA) (PAI2) 127 Pudendal artery 17
128 Plasmodium falciparum 204 Pudendal canal 14, 278
Pectinate line 14 Plasmodium vivax 204 Pudendal nerve 12, 12, 24
Pelvic inflammatory disease (PID) Platypelloid pelvis 21 Pudendal vein 13
149–150, 153 Polyarteritis nodosa (PAN) 226 Pulmonary embolism (PE)
Pelvic splanchnic nerves 12, 276 Polycystic ovary syndrome (PCOS) 241–242, 279
Pelvic ultrasound 155 83, 154, 318–319, 319, 331–332 Pulmonary surfactant 123
Pelvis Polyhydramnios 175 p-value 270–271
android 21 Polymorphic eruption of pregnancy Pyramidalis 275
anthropoid 21 (PEP) 337 Pyrazinamide 203
bony 26, 26 Portocaval anastomosis 13 Pyruvate 40
diameters of 11, 11f Posterior iliac artery 293
female 11, 11f, 17, 263 Posterior pituitary gland 74
gynaecoid 21 Postmenopausal bleeding 173 Q
male 17 Postpartum haemorrhage (PPH) QRS complex 327
nerve supply 12 153, 328–329, 329 Quadratus lumborum 19
platypelloid 21 Potassium, normal range for 172 Quadruple test 107, 285
true 11 Pouch of Douglas 17
veins 13 Prader–Willi syndrome 104, 105,
Peptide hormones 268 271, 288 R
Peptidoglycan 335 pRb (retinoblastoma protein) 38 Radiation
Perinatal mortality rate, definition Pre-eclampsia 157, 224, 329, 336 effective dose 140, 141
of 94 Pregnenolone 38–39 ionising 140, 140
Perineal body 25, 25 Premalignant diseases 338 non-ionising 140
Perineal tear, grade of 174 Premature ovarian failure 330 Radiotherapy 140, 141
Peripheral chemoreceptors 124, Pretibial myxoedema 65 side-effect of 142
126 Prevotella species 333 Ramipril 119, 240, 341
Perthes’ disease 279 Primary adrenocortical insufficiency Ras proteins 38
Pethidine 314 see Addison’s disease Rectal plexus 12
Phaeochromocytomas 67, 81, Primary hyperparathyroidism Rectum 263–264
217–218 39–40 Rectus abdominis muscle 278
Pharmacokinetics 236 Primary peritoneal cancer (PPC) Rectus sheath 14, 22–23, 23
Pharyngeal arches 48, 49 227–228 Reduced fetal movement (RFM)
Phenylalanine hydroxylase 38 Primitive streak 48, 51 158
Phenylketonuria 38 Probe movements, in ultrasound Refraction 142
Phenytoin 240, 282 scanning 315 Relative risk, calculation of 97, 97
Pinta 197 Progesterone 68, 71, 82 Relaxin 75
Pituitary adenoma 338 Progesterone-only pill (POP) 123, Renal system, in pregnancy 120,
Pituitary gland 338 126, 275, 340 274–275
anterior 74 Prolactin 64–65, 72, 123 Renin 66
posterior 74 Prolactin-secreting adenomas 338 Renin–angiotensin–aldosterone
Placenta Propofol 340 system (RAAS) 66
drugs transfer across 314 Prostaglandin E2 (PGE2) 39 Respiration
hormones secreted by Prostaglandin F2 alpha (PGFα) 39 controls of 124
288–289 Prostaglandin I2 (PGI2) 39, 280 stimulus to 126
transport across 289 Prostaglandins 39, 237 Respiratory distress syndrome 123
Placenta accreta 324 Prostanoids 280 Respiratory system changes in
Placental abruption 328, 342 Protein C deficiency 221, 345 pregnancy 127
Placental development 266 Proteinuria 168, 171, 329 Rhabdomyolysis 226
Placenta praevia 154, 174–175, Proteus mirabilis 201 Rhesus (Rh) D antigen 182
316–317 Psoas muscle 19, 275–276 Ribonucleic acid (RNA) 37
Index 353
U V W
Ultrasound 137, 139, 326 Vaccines 183–184 Warfarin 240, 243, 339–340
A-mode 139 Vagina 15–16, 24 Warm antibody autoimmune
B-mode 139 Vaginal artery 16 haemolysis 221
Doppler mode 139 Vaginal birth after caesarean Waterhouse–Friderichsen
M-mode 139 (VBAC) 326–327 syndrome 67
transabdominal 327 Vaginal candidiasis 244 Western blotting 42
transvaginal 326, 327 Vaginal clear cell carcinoma 216 Wharton’s jelly 289
Umbilical artery, single 324 Valid consent 93 World Health Organisation (WHO)
Umbilical cord 289 Variance 91, 95 neonatal mortality rate,
Umbilical cord prolapse 325–326 Varicella zoster immunoglobulin definition of 284
Ureaplasma 204 (VZIG) 154 osteoporosis, definition of 219
Ureters 15, 24 Varicella zoster virus (VZV) 170, perinatal mortality rate,
Urethra 277 196–197, 318, 323 definition of 94
female 278 Vasa praevia 154 reference ranges for semen
Urethritis 200 Vasopressin see Antidiuretic analysis 169, 171
Urinary bladder 14–15 hormone (ADH) Wound healing, cutaneous 224
Urinary tract infections (UTIs) Velamentous cord insertion Wound infection, risk factors for
169–170, 200–201 289 334–335
Urine, properties of 125 Very low-density lipoproteins
Urogenital sinus, male 281 (VLDLs) 42
Urogenital system, development of Vinblastine 240 X
48–49, 51, 52 Viruses 196, 196 Xeroderma pigmentosum 218
Uterine artery 25, 276 Vital capacity 131
Uterine fibroids 215, 215, 326, 326 Vitamin D 268, 268, 278–279
Uterine plexuses 13 Vitamin K 244 Y
Uterus 16–17, 264 Vitelline veins 52 Yaws 197, 333
endometrium 277 Vitellointestinal duct 281
round ligament 277 von Willebrand’s disease 221,
structural abnormalities 223, 242
Z
223 Vulval cancer 227 Zavanelli manoeuvre 158
Zopiclone 241