SELF-ASSESSMENT

Self assessment questions

Questions EMQ 2
For each statement regarding nutrition during pregnancy given
EMQ 1
below, choose the single most appropriate choice from the list
For each clinical situation choose the corresponding activity.
of options given. Each option may be used once, more than
a) No further action required
once or not at all.
b) Review in community in one week
a) Carbohydrate
c) Refer for opinion from another speciality
b) Energy
d) Perform urgent delivery 1 hour
c) Fibre
e) Referral for hospital review with 48 hours
d) Protein
f) Referral for hospital review same day
e) Essential fatty acids
g) Arrange immediate admission
f) Iron
h) Book outpatient US scan
g) Iodine
(i) A woman in her first pregnancy is seen by the com-
h) Vitamin D
munity midwife for a routine visit at 28 weeks. She
i) Vitamin B12
feels well, but is noted to have a blood pressure of
j) Calcium
140/92 and no proteinuria
(i) A precursor for the synthesis of prostaglandins
(ii) A woman in her third pregnancy at 30 weeks is seen
(ii) Used as an energy source when carbohydrate intake is
by her community midwife complaining of headache
insufficient
and epigastric pain. She has a blood pressure of 155/
(iii) A deficiency has been found to be linked to mental
98 and protein 2þ in her urine
retardation, cognitive deficit and growth restriction
(iii) A woman has a routine midwife review at 36 weeks
(iv) Supplementation is recommended in those with a BMI
and has 1þ protein in her urine with a blood pressure
>30 kg/m2
of 120/78
(iv) A woman has a routine midwife review at 36 weeks MCQ 3
and has 1þ protein in her urine with a blood pressure A 35-year old lady in the first trimester of her first pregnancy
of 130/82. She has a headache presents to her booking visit with a single painful genital ulcer.
She has no other symptoms and has no other past medical
MCQ 1
history. Which of the following would NOT feature in your
Which one of the following women does NOT require a
differential diagnosis for STI causes for symptoms in this lady?
glucose tolerance test by 16 weeks’ gestation according to
a) Syphilis
current guidance?
b) Herpes
a) A Caucasian woman in her second pregnancy who had
c) Trichomoniasis
gestational diabetes controlled by diet in her first
d) Donovanosis
pregnancy
e) Chancroid
b) A Pakistani woman in her first pregnancy with a BMI of 28
c) A Caucasian woman in her third pregnancy whose previ- MCQ 4
ous children weighed 4.2 kg and 4.6 kg at delivery For the patient described in MCQ 3 (above), which of the
d) A Caribbean woman in her first pregnancy who had following steps would not form part of your initial investiga-
glycosuria 1þ at 8 weeks and again at 12 weeks’ gestation tion and management plan?
e) A Caucasian woman in her second pregnancy with a BMI a) Taking a full sexual health history
of 45 b) Prescribe acyclovir
c) Perform HIV and syphilis serology
MCQ 2
d) Partner contact tracing
Which ONE of the following women does not need to be
e) Full examination of the genital skin
offered high dose folic acid of 5 mg/day in pregnancy?
a) Family history of neural tube defects EMQ 3
b) BMI>30 kg/m2 Pick the single most appropriate answer from the list below for
c) Patient is taking anti-depressants each of the clinical cases described:
d) Patient has type 1 diabetes mellitus a) The RMI is zero
e) Previous pregnancy affected by neural tube defect b) The RMI cannot be calculated
c) The RMI suggests a 75% risk of ovarian cancer
Catherine Aiken PhD MRCOG is a Clinical Lecturer in Obstetrics d) 40% of women with an ovarian cyst will have an RMI in
and Gynaecology at Addenbrooke’s Hospital, Cambridge, UK. this range
Conflicts of interest: none declared. e) The RMI is 150

OBSTETRICS, GYNAECOLOGY AND REPRODUCTIVE MEDICINE 26:9 280 Ó 2016 Elsevier Ltd. All rights reserved.
 SELF-ASSESSMENT
f) The RMI suggests a very low risk of cancer
g) The RMI is less than 25
h) The RMI is not relevant to assessment of this patient
(i) A 75-year old woman attends the gynaecology clinic
following a referral for abdominal pain and bloating.
Her ultrasound scan shows bilateral, multiloculated
masses in the adnexae. Her serum ca125 level is 80
(ii) A 35-year old woman is seen as an emergency in A&E
with abdominal pain. She is well enough to go home,
but returns for a pelvic ultrasound scan that shows a 7
cm left ovarian mass with mixed solid and cystic
areas. Her ca125 result is pending
(iii) A 67-year old woman is referred to gynaecological
oncology services with abdominal distension and a
change in bowel habit. She has a ca125 of 40. Her
pelvic ultrasound scan shows a 4 cm simple cyst on
the right ovary
MCQ 5
A 55-year old postmenopausal woman attends the gynaecol-
ogy clinic following an ultrasound scan on which an ovarian
cyst has been incidentally detected. The scan shows a 5 cm left
ovarian cyst with solid components. Her ca125 level is 20.
Which one of the following management options will you
recommend?
a) Repeat pelvic ultrasound scan and ca125 in 4 months to
reassess
b) Staging laparotomy in a gynaecological cancer centre
c) Laparoscopic salpingo-oophorectomy in local unit
d) Laparoscopic salpingo-oophorectomy in a gynaecological
cancer centre
e) Total abdominal hysterectomy and salpingo-oophorectomy
in local unit
MCQ 6
Which one of the following statements is true regarding ma-
ternity dashboards in the UK?
a) There are uniform standards across all units to allow direct
comparisons
b) Parameters are divided into three groups: safety, workload
and quality
c) Information from dashboards should not be used to alter
training
d) When an indicator has been ‘green’ for some time, it can be
removed from the dashboard
e) Dashboards should be used to monitor performance on a
monthly basis
EMQ 4
From the options listed, chose the single most appropriate
answer for each of the descriptions given below:
a) The Royal College of Obstetricians and Gynaecologists
b) Patient Advisory and Liaison Service
c) Maternity Task Force
d) Key Performance Indicators
e) Local Commissioners
f) National Patient Safety Foundation
g) The Maternity Dashboard
OBSTETRICS, GYNAECOLOGY AND REPRODUCTIVE MEDICINE 26:9
h) Commissioning for Quality and Innovation
(i) Issued definition of safety as avoidance, prevention
and amelioration of adverse outcomes generated
during the process of care
(ii) A clinical governance tool that helps to monitor out-
comes on a monthly basis by comparing the observed
outcomes with the pre-determined gold standards (i.e.
goals) based on regional and national data or based on
robust, high quality scientific publications
(iii) Suggested Red, Amber and Green (RAG) traffic light
system to display the data on maternity dashboards
Answers
EMQ 1 answers
(i) e. This woman potentially has pregnancy-induced hy-
pertension and needs to be referred for consultant review,
but being well with no protein this does not have to be
immediately.
(ii) g. This lady has signs and symptoms of pre-eclampsia
and should have an urgent review in an obstetric unit.
(iii) b. It would be worth checking she does not have a urine
infection that may also cause proteinuria. Having
excluded this then surveillance for pre-eclampsia needs to
be increased and she should be told of symptoms to
report for further review.
(iv) f. Although the blood pressure is normal she has potential
symptoms of pre-eclampsia and new onset of proteinuria.
She should be sent for further assessment in an obstetric
unit.
MCQ 1 answer
B
The ethnic origin of this woman means she should have a GTT
in pregnancy, but between 24 and 28 weeks’ gestation. Pre-
vious Gestational diabetes, previous infant >4.5 kg, and BMI
of 45 should all have early GTT in subsequent pregnancies.
MCQ 2 answer
C
Anti-depressant therapy in pregnancy does not mandate high
dose folic acid. All of the other women in this scenario should
be offered folic acid at the higher dose of 5 mg daily.
EMQ 2 answers
(i) Essential fatty acids
(ii) Protein
(iii) Iodine
(iv) Vitamin D
MCQ 3 answer
C
Herpes or syphilis are the most common STI causes of gen-
ital ulceration and should be tested for in conjunction with
local sexual health services. Rare causes include Donova-
nosis and Chancroid and non-STI causes such as fixed drug
eruptions, trauma and vulvar malignancies should also be
considered. Trichomoniasis does not usually cause genital
ulceration.
281 Ó 2016 Elsevier Ltd. All rights reserved.
 SELF-ASSESSMENT

MCQ 4 answer MCQ 5 answer

B D
A full sexual health history should be taken including details This woman’s RMI is 60 (3  1  20), which puts her at
of partners in the previous 3 months and any previous syphilis moderate risk of ovarian cancer. Women at low risk of cancer
testing dates and results. Examination of the genital skin (i.e. less than 3%) can be managed in a general gynaecology
should be carried out and PCR testing for herpes (and syphilis unit. This involves serial ultrasound scans and serum CA125
if locally available). Sexual health teams may also be able to measurements every four months over a year. Women at
perform dark ground microscopy in their clinics. moderate risk of cancer (i.e. 20%) should be offered a lapa-
Serology should be taken for syphilis and HIV. Serology roscopic oophorectomy in a cancer unit. Those who have a
for herpes in pregnancy is often useful and should be dis- high risk of cancer (i.e. over 75%) should be managed in a
cussed with the local sexual health team. The patient should cancer centre with full staging.
also be tested for Chlamydia and Gonorrhoea. Partners
MCQ 6 answer
should be encouraged to attend a sexual health clinic for re-
E
view, testing and/or treatment. The patient should be advised
The ‘Maternity Dashboard’ is a clinical governance tool that
to avoid all sex until the ulcer has healed and the partner
helps to monitor outcomes on a monthly basis by comparing
reviewed.
the observed outcomes with the pre-determined gold stan-
If herpes is later confirmed, acyclovir may be indicated and
dards. The RCOG’s original maternity dashboard divided these
this treatment in pregnancy should be carefully explained. The
parameters into three groups; activity, workload and quality.
risk of transmission to the fetus at this gestation is low and
However, it is vital that the Maternity Dashboard should
would be unlikely to affect the mode of delivery.
reflect the needs of an individual maternity unit and the pa-
EMQ 3 answers rameters should be chosen by the local multi-disciplinary team
(i) C based on the issues facing the individual maternity unit.
This woman’s RMI is 480 (3  3  80). An RMI of >250 gives
EMQ 4 answers
a >75% risk of ovarian cancer.
(i) B
(ii) B
This is a national organization that campaigns for the highest
This woman’s RMI is relevant to her care, but cannot be
possible standards in medical care.
calculated until the ca125 level is back.
(ii) G
(iii) A
A tool that has been widely adopted across the UK since it
This woman’s scan shows only a simple cyst with no
was first rolled out.
suspicious features. This makes the ultrasound (U) component
(iii) A
of the RMI ¼ 0 and therefore the entire score is zero. Other
The RCOG was instrumental in setting up the principles of the
causes of raised ca125 (particularly bowel-related pathologies)
dashboard and determining how it should be used within units.
should be sought in this case.

OBSTETRICS, GYNAECOLOGY AND REPRODUCTIVE MEDICINE 26:9 282 Ó 2016 Elsevier Ltd. All rights reserved.