SBA – MRCOG/MD Part 2 Set-1

1. You are asked to see a pregnant woman who has been referred for a chest X-ray for suspected pneumonia at 26 weeks gestation. She is worried about the impact of exposure of ionizing radiation on her pregnancy. What is the accepted cumulative dose of ionizing
radiation in pregnancy?

A. 50 mGy
B. 100 mGy
C. 125 mGy
D. 150 mGy
E. 200 mGy

2. You are asked to see a 36-year-old multiparous woman who is keen to proceed with a uterine artery embolization for fibroids. However, she is unsure of the impact of UAE on future pregnancies. Which of the following is true in relation to pregnancies following
uterine artery embolization?

A. There is a lower risk of miscarriage when compared to pregnancy after myomectomy
B. There is an increased risk of fetal growth restriction
C. There is an increased risk of post-partum haemorrhage
D. There is an increased risk of preterm delivery
E. There is no increase in the rate of caesarean section

3. A 23-year-old primiparous woman has been diagnosed with pulmonary tuberculosis at 33 weeks gestation. What is the impact on the pregnancy?

A. Increased risk of congenital anomaly
B. Increased risk of placental abruption
C. Increased risk of pneumonia
D. Increased risk of pre-eclampsia
E. Increased risk of preterm rupture of membranes

4. You prescribe cyproterone acetate to a 28-year-old woman presenting with simple hirsutism. What type of medication is cyproterone acetate?

A. Aldosterone antagonist
B. Anti-oestrogen
C. Diuretic
D. Oestrogen receptor agonist
E. Progestogen

5. A 25-year-old primigravid woman presents in her first trimester. You note from her blood results that she is hyperthyroid. Which of the following is correct regarding her medication?

A. Carbimazole is preferred to prophylthiouracil
B. Fetal thyroxine levels may be affected
C. The risk of agranulocytosis is lower with carbimazole than prophylthiouracil
D. Treatment doses will need to be increased later in pregnancy
E. When hyperthyroidism is seen with hyperemesis gravidarum, antithyroid drugs should be given

6. You are asked to see a 32-year-old nulliparous woman and her 34-year-old husband in infertility clinic. They are both fit and healthy and have been trying to conceive for almost two years. On reviewing the laboratory investigations of the semen analysis, you
find that the sperm count is <2 x 106/ml in two separate samples. All other parameters are normal, as are the FSH, LH and testosterone. What is the most likely cause?

A. Congenital absence of the vas deferens
B. Kallmann syndrome
C. Paternal age
D. Primary testicular failure
E. Varicoele

7. You are asked to review the blood investigations of a primiparous woman who is 22 weeks pregnant. You notice she has a raised inhibin A level. What complication is associated with a high inhibin A level?

A. Oligohydramnios
B. Placental abruption
C. Pre-eclampsia
D. Spontaneous miscarriage
E. Trisomy 21

8. Caesarean section (CS) is associated with the following risks, except:

A. A 1-in-100 risk of bladder injury requiring repair
B. After their first CS, 4-8 in 1000 women will have an increased risk of placenta praevia or placenta accreta
C. An increase by 50% of the overall risk profile4 with emergency CS when compared to elective CS
D. An increased risk of stillbirth in future pregnancies
E. Neonatal lacerations in 1% of caesareans

9. A 32-year-old woman contemplating her first pregnancy comes to see you in the pre pregnancy clinic. She has had epilepsy since the age of 10. The following are true about anticonvulsants in pregnancy, except:

A. Clonazepam is not teratogenic
B. Phenobarbitone cross the placenta but carbamazepine does not
C. Phenytion is associated with congenital heart defects
D. The teratogenic effect of valproate is dose-dependent
E. The teratogenic risk of a combined anticonvulsant regime, which includes valproate, carbamazepine, and phenytoin, is as high as 50%

10. The cardiovascular system undergoes numerous changes in pregnancy in order to adapt to the demands of the developing fetus and labour. Which of the following parameters does not change?

A. Blood volume
B. Capillary refill time
C. Cardiac output
D. Heart rate
E. Stroke volume

11. 1. A 24-year-old woman presents in clinic at 12 weeks gestation with monochorionic twins.
Upon discussing the risks associated with monochorionic twins, she asks you how
common twin-to-twin transfusion syndrome is. What is your answer?
A. 2%
B. 5%
C. 10%
D. 20%
E. 25%

12. 2. A GP refers a 58-year-old woman with a probable diagnosis of lichen sclerosis. Which of
the following is correct management?
A. A biopsy is required to confirm the diagnosis
B. Topical steroids can be applied long-term
C. Topical treatment should include the vagina
D. Treatment is required regardless of whether the woman has any symptoms
E. Women should be seen every three months

13. When presenting risk, the term ‘very rare’ is equivalent to:
A. 1 in 10,000
B. 1 in 1000
C. A person in a large town
D. A person in a small town
E. A person in a village

14. Of women who have recurrent pregnancy loss (i.e. three or more first-trimester
miscarriages), what percent will have anti-phospholipid antibodies?
A. 5%
B. 15%
C. 25%
D. 30%

E. 40%

15. A 37-year-old primigravida woman presents at ten weeks gestation to antenatal clinic.
She has been referred because she has a known diagnosis of myasthenia gravis. What is
the mainstay of treatment?
A. Baclofen
B. Beta-interferon
C. Gabapentin
D. Isoniazid
E. Pyridostigmine

Answers

1. Answer: A
   The accepted background cumulative dose of ionizing radiation during pregnancy is 50 mGy (5 rad), with little evidence to suggest any change in risk of major malformations at this level.
2. Answer: C
   There is an increased risk of PPH.
3. Answer: D
   Pulmonary TB which is diagnosed late in pregnancy increases the risk of pre-eclampsia, acute respiratory failure, and preterm labour. Extrapulmonary TB affects the mother’s health but does not alter the course of the pregnancy, mode of delivery, or the rate of pre-eclampsia.
4. Answer: E
   Cyproterone acetate is a strong progestogen which reduces plasma luteinzing hormone levels, thereby lowering testosterone and androstenedione levels. It also acts as an anti-androgen peripherally. Spironolactone is a diuretic which acts as an aldosterone antagonist to reduce hirsutism.
5. Answer: B
   Both carbimazole and propylthiouracil cause agranulocytosis and are equally effective in pregnancy. Treatment dose can be either reduced or stopped in the second and third trimesters. Antithyroid medication is ineffective in cases of hyperemesis gravidarum because there is no increase in thyroid activity.
6. Answer: A
   Azoospermia with normal hormone levels suggests an obstructive cause such as congenital absence of the vas deferens, vasectomy, and infection.
7. Answer: C
   An isolated high level of inhibin A in the second trimester is associated with preterm delivery,pre-eclampsia, low birth weight, and intrauterine death.
8. Answer: A
   There is an increased risk of antepartum stillbirth, 1-4 in every 1000 women. Risk of bladder damage is around 1 in 1000 CS. The risk of fetal laceration at CS is 1-2 per 100 procedures. There is an increased risk of repeat emergency CS when vaginal delivery is attempted in subsequent pregnancies.
9. Answer: B
   Valproate, phenobarbitone, carbamazepine, and primidone all cross the placenta. Phenytion and valproate are associated with congenital heart defects. The risk of teratogenicity increases with the number of drugs. For patients taking two or more anticonvulsants the risks is 15%. For those taking valproate, carbamazepine, and phenytoin, the risk is as high as 50%. The teratogenic effect of valproate is dose-dependent. The risk of teratogenicity increases sixfold in mothers taking more than 1 g of valproate per day. Benzodiazepines including clonazepam are not teratogenic.
10. Answer: B
    Cardiac output (CO), stroke volume (SV), and heart rate (HR) increase in pregnancy. Remember CO = SV x HR. Stroke volume is the amount of blood pumped through the ventricles in one heartbeat. Therefore, CO is the amount of blood pumped through the ventricles in one minute. In pregnancy, cardiac output increases by approximately 40%, from 4.5 L/minute to approximately
    6 L/minute. This is due to a 30% increase in stroke volume and 10% increase in heart rate. Blood volume increases by 30% in pregnancy. By comparison, plasma volume increases by 40%. This leads to a dilutional anaemia in pregnancy, which is most obvious in the first trimester.
11. Answer: C
    TTTS is seen in 10-15% of all monochorionic pregnancies and is associated with multiple
    placental vascular anastomoses between the fetal circulations. Without treatment, it is associated
    with an 80-100% mortality rate; 15-50% risk of disability is seen amongst those who survive.
12. Answer: B
    Histological diagnosis is reserved for diagnostically difficult cases or those which are resistant to
    treatment. The vagina and cervix are generally not affected and treatment is required only if
    symptoms occur. The frequency of follow-up is variable, but bleeding and ulceration should be
    reported.
13.  Answer: C
14. Answer: B
    In women with recurrent pregnancy loss, 10-20% have detectable antiphospholipid antibodies. If
    left untreated, the risk of a further pregnancy loss can be up to 90%.
15. Answer: E
    Myasthenia gravis is a rare autoimmune condition caused by antibodies against the nicotinic
    acetylcholine receptors. It is more commonly seen in women, and 40% have an exacerbation in
    pregnancy. Pyridostigmine is a long-acting anticholinesterase drug used to treat myasthenia
    gravis. Other medications which may also be considered include corticosteroids, azathioprine
    and plasmaphoresis.

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