Gynae MCQ pool Flashcards
While you are dissecting on the medial aspect of the psoas muscle at the level of the pelvic brim, which of
the following structures is most likely to be injured?
a. External iliac vein
b. External iliac artery
c. Ureter
d. Genito-femoral nerve
e. Obturator nerve
Answer: E (probably best answer – C next best)
– the obturator nerve descends
through the psoas major muscle, leaving the MEDIAL border of the muscle at the LEVEL of the PELVIC
BRIM. However, it does say that it is more likely to be damaged in the lower pelvis where it lies in extraperitoneal fat and is liable to damage during operations to remove pelvic lymphatics.
Which vessel is not contained in ischiorectal fossa?
a. perineal
b. pudendal
A
Which of the following is divided in performing an omentectomy?
a. Omental branch of the abdominal aortic artery
b. Middle colic artery
c. Epigastric artery
d. Gastroepiploic artery
e. Median sacral artery
D
Pubourethral ligament contains?
a. collagen
b. collagen, elastin
c. collagen, elastin, muscle
C
Histologically the ligaments consist of smooth muscle, elastin, collagen, nerves and, blood vessels
In anatomical position, the angle of the vagina is upwards and backwards**
a. 90 degrees
b. 135 degrees
c. 260 degrees
d. 310 degrees
B
Where does the paravaginal fascia insert?
a. Arcus tendineus
b. Iliopectineal line
c. Urogenital diaphragm
d. Perineal body
e. Sacrospinous ligament
A
The structure posterior to the external iliac artery and vein and would dissect medially off the psoas
muscle is:
a. Superior gluteal artery
b. Obturator nerve
c. Ureter
d. Uterine artery
Likely C
Probably ureter as the obturator nerve lies very deep to the external iliac artery, despite the ureter not
being truly posterior to the external iliac artery
How many oocytes are left by the time a woman reaches puberty?
a. 4000
b. 15,000
c. 30,000
d. 100,000
e. 400,000
E
What histological change occurs in the post-menopausal ovary?
a. Increased number of granulosa cells
b. Increased immature oocytes
c. Increased stromal cells
d. Increased theca interna cells
C
Cystic glandular hyperplasia associated with?
a. cyclical HRT
b. depot MPA
c. NIDDM
d. COCP
C (unopposed oestrogen)
Which of the following conditions require urgent surgical treatment?
a. acute appendicitis
b. acute cholecystitis
c. acute pancreatitis
d. acute pyelonephritis
e. acute osteomyelitis
A
60 yo with several year history of LIF pain. Temp 38, raised WBC (15,000), few WBC in urine, unwell. Most
likely diagnosis?
a. acute appendicitis
b. acute cholecystitis
c. acute diverticulitis
C
Effect of electrosurgical waveform with high current, low voltage and increase tissue temperature rapidly
(>100 degrees to result in vaporization)**
a. Cut
b. Fulguration
c. Coagulation
d. Blend
e. Desiccate
A
After a vaginal hysterectomy, the patient is brought back to theatre for primary haemorrhage. In ligating
the internal iliac arteries, which of the following structures is most likely to be injured?
a. external iliac arteries
b. external iliac veins
c. ureters
d. obturator nerve
e. common iliac arteries
Most likely B, possibly C
a. external iliac arteries (lateral and should not come into play)
b. external iliac veins (most likely answer – will sit just infero-lateral to internal iliac and is
bulbous at level of bifurcation)
c. ureters (always in play even with a gynaecologist doing neurosurgery, but crosses internal iliac
from medial to lateral and should be below it at level of internal iliac)
d. obturator nerve (you are going medial to psoas and so are far enough away from the nerve)
e. common iliac arteries (should be below it at level of internal iliac)
Difficult endometriosis TAH. Sudden profuse bleeding from L paracervical tissue. Mx?
a. large clamp laterally
b. pack and call for help
c. clamp aorta above pelvic brim
d. clamp common iliac
e. finger to occlude common iliac then identify ureter
B
Day 1 post TAH for benign pathology, the patient is SOB and has severe central chest pain. O/E – T 36.7,
PR 110, RR 28, BP normal. CXR shows bibasal atelectasis, WCC 11, pO2 66 mmHg. Next step?
a. Antibiotics
b. V/Q
c. Pulmonary angiogram
d. Blood transfusion
B
Raised temp 12-24 hrs following TAH?
a. vault cellulitis
b. septicaemia
c. DVT
d. Reaction to transfusion
B
A 30 yo with TAH for intraepithelial Ca of the cervix. Flushed, temp 39 C, PR 140/min, RR 24, clear chest.
Most likely diagnosis?**
a. PE
b. Pelvic sepsis secondary to bacteroides fragilis
c. Beta Strep
d. Pelvic vein thrombosis
e. Reaction to blood
B
A 100kg woman had a routine TAH for uterine fibroid. On post operative day 5, temp 38, there was profuse watery discharge from the wound. What is your management?
a. return to theatre
b. commence on antibiotics
c. apply pressure dressing
d. perform an IVP
e. no treatment needed
D - intravenous pyelogram
5 days post TAH, vertical incision, serous ooze, Mx?
a. nothing
b. Steristrip
c. antibiotics
d. probe
D - probe with swab
A TAH, BSO was performed for extensive endometriosis. The operation took approximately 2 hours. On
day 1 post op review, the patient c/o numbness on the anterior aspect of the right thigh and weakness on
flexion of the right hip. Which of the following is most likely?
a. patient has a psoas haematoma
b. pressure effect of the retractor during the long operation
c. patient has a pelvic haematoma
d. your assistant has been leaning on the thigh
e. Duplex Doppler to exclude DVT
B
Difficult hysterectomy with endometriosis, significant blood loss of 2 litres throughout the procedure. At
the end of the procedure is noted to have a haemostatic suture too close to what you thought was the
ureter. Your next options are:
a. Do nothing but closely observe in the next couple of days
b. Remove the suture
c. IV indigo carmine and watch the dye through the ureter
d. Do a cystotomy at the operation and pass some catheters up the bladder to make sure the
ureter is patent
D - but cystoscopy is probably more appropriate
Difficult TAH for endometriosis, difficulty with haemostasis. Finally haemostasis secured but stitch
uncomfortably close to left ureter at top of vaginal vault.
a. Do nothing, observe closely post-op
b. Ureterotomy at level of pelvic brim and insert ureteric stent
c. Cystotomy and insert stent into left ureter
d. Injection of indigo carmine IV and follow dye flow through ureter
e. Remove suture
C - but cystoscopy likely more appropriate
At end of TAH there is fluid in pelvis that looks like urine. What do you do?
a. Sterile milk into bladder
b. Dissect out ureters
c. Ask anaesthetist to give IV indigo carmine
d. Redivac drain and close
e. IDC x 10 days and close
C
During a TAH for severe endometriosis a 1cm longitudinal laceration is made in the sigmoid colon. Your
management would be:
a. Anterior resection
b. Hemicolectomy
c. Repair defect in colon
d. Repair defect and form transverse loop colostomy
e. Repair defect and form caecostomy
C
The proven benefits of subtotal hysterectomy include:
a. Reduced hospital stay
b. Better sexual function
c. Reduced risk of vault prolapse
d. All of the above
e. None of the above
E
You are performing a laparoscopy for infertility and when inserting the Verres needle get a constant
stream of blood coming out of it. You remove the needle and the anaesthetist says her HR/BP etc are
stable. Do you?
a. Abandon laparoscopy and discharge patient home
b. Observe for 48 hrs
c. Laparoscopy with Hassan entry
d. Laparoscopy with Verres in LUQ
e. Do laparotomy
E
The highest mortality with laparoscopic tubal ligation is due to
a. Vascular injuries
b. Perforation of abdominal viscus
c. General anaesthetic
d. Air embolism
e. Infection
C
When would neo-uretero-cystotomy be the most appropriate procedure?
a. ureter divided closer to the trigone
b. ureter divided at the pelvic brim
c. ureter ligated and immediately recognised
d. ureter ligated and recognised just prior to peritoneal closure
e. ureter clamped for 30 secs
A
When would re-anastomosis with splint be most appropriate?
a. ureter divided closer to the trigone
b. ureter divided at the pelvic brim
c. ureter ligated and immediately recognised
d. ureter ligated and recognised just prior to peritoneal closure
e. ureter clamped for 30 secs
B, or possibly D - if divided for prolonged time a splint is needed)
a. ureter divided closer to the trigone (close to trigone assume not enough distal ureter for
primary anastomosis and would suggest hitch and reimplantation)
b. ureter divided at the pelvic brim (most likely answer- but I would prefer a Boari flap at this
level)
c. ureter ligated and immediately recognised (this dose tell us where injury has occured, so not
the most appropriate answer also ligating it would disrupt blood supply so I would resect
before anastomosis)
d. ureter ligated and recognised just prior to peritoneal closure (presume ligated for a while so
woud require resection of likely avascular area prior to anastomosis)
e. ureter clamped for 30 secs (crushing injury from clamp–> resect before ansstomosis
Reimplantation is treatment of choice due to the high chance of stenosis with reanastomosis but there are
limited options with high injuries. D/W Naven: Some people could suggest that uretreoureterostomy in
the pelvis should always be accompanied by psoas hitch and reimplantation. But ureteroureterostomy OK
in abdo and pelvis above cardinal ligament.
When is uretero-ureteral anastomosis most appropriate?
a. ureter divided closer to the trigone
b. ureter divided at the pelvic brim
c. ureter ligated and immediately recognised
d. ureter ligated and recognised just prior to peritoneal closure
e. ureter clamped for 30 secs
B
Reimplantation is treatment of choice due to the high chance of stenosis with reanastomosis but there are
limited options with high injuries. D/W Naven: Some people could suggest that uretreoureterostomy in
the pelvis should always be accompanied by psoas hitch and reimplantation. But ureteroureterostomy OK
in abdo and pelvis above cardinal ligament.
Ten days after a vag hyst a patient developed a watery vaginal discharge. IVP demonstrated an ureterovaginal fistula 3cm above the ureterovesical junction. What is the appropriate treatment?
a. Uretero-ureteral reanastamosis
b. Reimplantation of the ureter
c. Perform a Boari flap
d. End to end reanastomosis
e. Insertion of a suprapubic catheter and await spontaneous closure
B
You are performing an endo-cervical curettage, which of the following is correct?
a. Dilate internal os, uterine curettage then endocervical
b. Dilate internal, endocervical curette, uterine curette
c. Endocervical curette, dilate internal os then uterine
d. Uterine curette, dilate internal os, endocervical curette
C
Suction curettage for missed abortion at 10/40. What size suction catheter should you use?
a. 6
b. 8
c. 10
d. 12
e. 14
C
Perforated uterus at D&C with haemorrhagic shock. Most likely site of perforation?
a. fundal
b. anterior
c. posterior
d. cervical
e. lateral
Answer: E (location of vessels)
While performing a suction TOP, the uterus is perforated and omentum pulled down to the external os.
Management?
a. observe
b. AXR and observe
c. Hysterectomy
d. Laparoscopy
e. Laparotomy and oversew defect
D
During TOP, uterus is perforated. Safest option is:
a. hysterectomy
b. observe
c. laparoscopy
d. laparotomy
C
.A woman had a termination of pregnancy at 8/40 gestation at a local clinic under LA. The cervix was
difficult to dilate and the uterus appeared to be perforated during this dilation. There was no bleeding or
pain. A TVS was performed and showed a viable 8/40 fetus with an intact sac. What is the most
appropriate management?
a. Continue with the termination
b. Transfer to hospital and continue termination under GA
c. Insert a cervagem vaginally and wait 4 hrs then attempt the suction termination
d. Perform a laparotomy and repair the defect, continue with suction termination with
hysterotomy and removal of POC if necessary
e. Stop the procedure and wait 1-2 weeks then reconsider
TeLindes and UTD state that if perforation occurred with blunt instrument (sound or dilator) then the
procedure can be continued under ultrasound guidance. If concerns exist around bleeding laparoscopy is
done and the procedure can be finished under laparoscopic guidance
Answer ?E
ND YAG laser hysteroscopy. Which medium?
a. CO2
b. Glycine
c. Dextrose
d. Sorbitol
e. N Saline
E
You are doing a hysteroscopic resection of uterine septum and no complications. Just about to remove
gloves when note brisk PV bleeding with no obvious vaginal or cervical lesion. Mx?
a. pack vagina and cervix with betadine gauze
b. laparotomy
c. look with hysteroscope
d. foley catheter in uterus
e. blood product Tx – packed cells/FFP/ cryoprecipitate
D
Operative hysteroscopy – when are you most likely to perforate?
a. Dividing septum
b. Submucous fibroid resection
c. Rollerball
A
Advantages of hysteroscopic scissors tha slipt over scope but in sheath.
a. Cost
b. Flexible distance between scope and scissors
c. Heavier more robust rigid scissors possible
d. Scissors only take up 1/4 of view
C
The patient had a radical hysterectomy and in the immediate post-operative period has difficulty walking
and the next day she has paraesthesia over her left thigh as well as an absent patella jerk. Which of the
following nerves would be appropriate?
a. Obturator
b. Femoral
c. Internal pudendal
d. Sciatic
B
When you are doing a radical hysterectomy you make a hole in the external iliac vein. What is you
immediate management?
a. put a finger over the hole
b. put a sponge over the hole
c. put a Kelly clamp over the hole
d. put a Kelly clamp distal to the hole
e. put a Kelly clamp proximal and distal to the hole
A (Kelly clamp is similar to an artery clip)
During a radical hysterectomy the uterine artery is divided at which of the following:
a. At its origin adjacent to the hypogastric artery
b. Adjacent to the ureter
c. Where it meets the uterus
d. In the wall of the uterus
A
A 35 yo decided on hysterectomy and bilateral BSO for intractable chronic PID. She has heard that
hysterectomy is associated with change in sexual function, decreased energy and loss of a sense of wellbeing. You counsel her that?
a. It will not affect her orgasm
b. She will experience no changes to sexual function as long as one ovary is left
c. Her sexual response will be affected by her and her partner’s response to the operation
d. Her energy levels will be unchanged as long as she takes oestrogen
C
Small cyst found in midline at the fourchette. Most likely
a. Bartholin’s cyst
b. Epidermal inclusion cyst
c. Sebaceous cyst
d. Gartner’s duct cyst
B
A small lump is noted in the vagina in the region of the posterior fourchette. It is most likely to be:
a. Epidermoid cyst
b. Sebaceous cyst
c. Gartner’s duct cyst
d. Bartholin’s cyst
A
Accepted time of resting for a girl who has sustained genital trauma?
a. 20 mins
b. 6 hrs
c. 24 hrs
d. 3 days
e. 4 days
C (as per UTD)
The amount of time before surgery that clear fluids should be stopped in paediatric patients is?
a. 2 h
b. 6 h
c. 12 h
d. 24 h
e. Can eat up till time of surgery
A
Normal menstrual cycle exhibits the following hormonal changes. Which of the following is correct?
a. LH surge occurs 12 h before ovulation
b. LH surge is due to a positive feedback from relatively high oestrogen levels in the late
follicular phase
c. Short pulses of GnRH occur during REM sleep
d. Maximum rate of oogenesis occurs at the trough of gonadotrophin secretion
e. In puberty, there is rise of LH before FSH
B
Ovulation occurs 10-12 hours after the LH peak but the surge begins 34-36 hours prior to ovulation; LH
surge is due to a positive feedback from relative high levels of oestrogen in the late follicular phase; FSH
rises before LH during puberty; GnRH pulses during awake according to Kate. A, E are definitely incorrect,
D is probably incorrect. Maximal oogenesis is fetal?
What enables a follicle to become dominant over others?
a. Production of progesterone during luteal phase
b. Production of inhibin by those follicles destined for atresia
c. Production of oestradiol
d. Induction of prolactin receptors
e. Ooph-hypophyseal reflex
C
Oestrogen receptor present on all except?
a. rectum
b. uterosacral ligament
c. vagina
d. urethra
A
Blood Assay steroid – Which is direct measure of adrenal androgen activity?
a. Androstinedione
b. Cortisol
c. DHEAS
d. Testosterone
C
What will lower the SHBG?
a. Pregnancy
b. Weight loss
c. Oestrogen
d. Hyperinsulinaemia
D
Pregnancy, hyperthyroidism and oestrogen increase SHBG whilst corticoids, androgens, progestins, growth
hormones, insulin and IGF-I decrease SHBG
Main hormone secreted by the PCO ovary?
a. Testosterone
b. Androstenedione
c. Oestrone
d. Oestradiol
e. DHEAS
B
Which steroid has the most effect on serum concentration of lipoproteins:
a. Testosterone
b. Oestrogen
c. Natural progesterone
d. Synthetic progesterone
e. Glucocorticoids
E
Subcut oestradiol therapy exhibits the following differences when compared with oral oestrogen:
a. A physiological ratio of estradiol to estrone is achieved
b. Rarely causes endometrial hyperplasia
c. Leads to more abnormal changes in clotting factors
d. Is less likely to increase serum level of renin substrate
e. Is more effective in the prevention of osteoporosis
A
Oral – increases SHBG, TBG, Lipids, Corticosteriod binding globulin
Transdermal AS effective in bone preservation & osteroperosis, less effect on lipids
Oral – greatest effect on clotting factors
Physiological state = 2:1 oestradiol to oestrone. Oral preparations metabolised to oestrone by liver –
therefore physiological state not maintained.
In an obese postmenopausal woman the commonest hormone is
a. Oestriol
b. Oestradiol
c. Oestrone
d. Androstenedione
Answer: C main postmenopausal E2 = oestrone (from peripheral adipose tissue & aromatisation of
androstenedione in ovary – this comes from adrenals).
Time after ovulation for eggs to reach uterine cavity?
a. 5 hours
b. 36 hours
c. 1 day
d. 4 days
e. 7 days
D
For how long does an unfertilised ovum remain viable after ovulation?**
a. 12-24 hrs
b. 24-48
c. 72 hrs
d. 4 days
A
Most estimates range between 12-24 hours although retrieved eggs can be fertilised up to 36 hours of incubation. (Speroff)
What are the characteristics of beta hCG in early pregnancy?
a. enhances placental-fetal adrenal steroidogenesis
b. supports the corpus luteum
c. enhances the effects of maternal blocking antibodies
d. maternal serum level rises to a peak at 14w
e. is chemically and functionally similar to ACTH
B
HCG is produced by the syncytiotrophoblast to promote progesterone production by the corpus luteum
until placental progesterone supply is established (after 6 weeks). HCG also plays a role in spiral artery
angiogenesis (UTD). The alpha subunit is identical to that of TSH, LH and FSH. HCG levels peak at 8-11
weeks gestation
Young sexually active female with non-offensive white PV discharge. PH < 4.5. What is the cause?
a. Gardeneralla
b. Thrush
c. Physiological
d. Gonorrhoea
C
Which of the following is the earliest sign of female sexual response?
a. Increased HR
b. Uterine contraction
c. Vaginal transudation
d. Vasocongestion of the outer third of the vagina
e. Erection of nipples
?A
The first sign of sexual arousal in a woman is?
a. Enlargement of the clitoris
b. Enlargement of the labia majora
c. An increase in vaginal length
d. An increase in vaginal moisture
e. Skin flushing
D
The most common cause of inhibition during the excitement phase of arousal in marital sex is?
a. Menopause
b. Hysterectomy
c. Fear of pregnancy
d. Marital discord
e. Empty nest syndrome
D
A woman presented to you with lack of sexual excitement. What is the most likely reason?
a. Fear of pregnancy
b. Poor coital techniques
c. Marital discordance
d. Endometriosis
e. Pelvic congestion syndrome
C
Match drug with effect in endometriosis
a. GnRH agonist
b. Danazol
c. Both
d. Neither
Delays return of ovulation after cessation
Hot flushes
An increase in LDL-cholesterol
Delays return of ovulation after cessation
Answer: D
Hot flushes
Answer: C
An increase in LDL-cholesterol
Answer: B
(Danazol increases LDL and total cholesterol, and decreases HDL)
Which medication is not used in treatment of menorrhagia?
a. neostigmine bromide
b. oestrogen
c. GnRH agonist
d. Progesterone
e. Methyl testosterone
A
(side effect of methyltest = amenorrhoea)
Danazol is associated with all EXCEPT
a. Fluid retention
b. Acne
c. Virilisation
d. Exacerbation of fibrocystic disease of breasts
D
Which action of the following anti androgens is the least accurate?
a. Cyproterone acetate acts on the 5 alpha reductase receptor
b. Spironolactone acts on the DHT receptor as well as 5AR receptor
c. Cimetidine acts as a weak binder to DHT receptor
d. Flutamide is a non-steroidal anti-androgen
e. Finasteride 5AR blocker
A
Cyproterone and spironolactone bind to androgen receptor and exert mixed agonism-antagonism.
Flutamide is a pure antiandrogen and blocks receptors with competitive inhibition (Speroff). Spironlactone
competitively inhibits DHT and 5AR. Cyproterone competitively inhibits DHT. Flutamide inhibits nuclear
binding of androgens but has weaker affinity than cyproterone or spironolactone. Cimetidine has a weak
anti-androgenic effect on DHT receptors. Finasteride is a specific inhibitor of 5AR with some activity on
DHT (Novak). Testosterone by 5 AR (ketoconazole/spironolactone/finasteride) → DHT by androgen
receptor complex (flutamide, cyproterone, spironolactone)
The most effective anti-androgen available is?
a. Danazol
b. MPA
c. Dexamethasone
d. Spironolactone
e. Cyproterone
E
Hormones with antiandrogen action include the following, except:
a. Spironolactone
b. Cyproterone acetate
c. Cimetidine
d. Flutamide
e. Tamoxifen
E
Tamoxifen has been proven to?
a. Reduce hospital admissions with cardiac disease
b. Reduce bone fracture
c. Be associated with hyperplasia
d. All of them
e. Lower total and LDL cholesterol
D
The effects of tamoxifen are uncertain with prevention of bone loss in postmenopausal women but
premenopausal women experienced substantial bone loss; reduces total cholesterol and LDL cholesterol;
less coronary heart disease; association with endometrial hyperplasia and cancer
Drugs which cause haemolytic anaemia
a. penicillin
b. methyldopa
c. cefoxitin
d. all of the above
e. none of the above
D
All of the following drugs are associated with impotence except?
a. cimetidine
b. Aldomet
c. Salzopyrine
C
All of the following are associated with impotence except?
a. Spinal cord lesion
b. Methyldopa
c. Salazopyrine
d. Hyperprolactinaemia
e. Chronic renal disease
C
What is the most common factor associated with ejaculatory impotence?
a. Alcohol
b. Diabetes
c. Methyldopa
d. Marital discordance
e. Peyronie’s disease
D
Which is right?
a. medroxyprogesterone acetate and virilisation of female fetus
b. Clomid and alopecia
“Answer: A
BOTH ARE CORRECT”
Select the correct option regarding side effects of hormone drugs
a. Depo Provera is well documented to cause congenital abnormalities in infants
b. Medroxyprogesterone acetate causes virilisation of male infants
c. Clomid is associated with hair loss
d. Bromocriptine is associated with hypertension
C
Clomid can rarely cause hair loss, bromocriptine occasionally causes both hypertension and hypotension.
Quite difficult to virilise a male infant.
Select the incorrect option regarding the side effects of hormonal agents:
a. Depo-provera is well documented to cause congenital abnormalities
b. Medroxyprogesterone acetate causes fetal virilisation
c. Clomiphene is associated with hair loss
d. Bromocriptine is associated with hypertension
e. Venous thrombosis is associated with oestradiol implants
A
Severe acne, before Rx with retinoic acid needs?
a. HCG
b. FSH
c. Oestrogen
A
What is the recognised clinical action of the antiprogestins?
a. Endometriosis
b. Post coital contraception
c. Hot flushes
d. Endometrial hypoplasia
B
Mifepristone can be used for emergency contraception and to a lesser extent endometriosis
The most common side effect that causes discontinuation of selective serotonin reuptake inhibitors is?
a. Cardiac dysfunction
b. Sexual dysfunction
c. Pulmonary hypertension
d. Anticholinergic effects including dry mouth and constipation
e. Sedation and lethargy
B
Starting dose of bromocriptine?
a. 1.25 mg nocte increasing to 2.5 mg BD with food over 2/52
b. 1.25 mg nocte increasing to 10mg /day over 2/52
c. 1.25 mg tds initially and increase
A
Reason for failure of bromocriptine treatment?
a. Under dosage
b. Non-compliance
c. Intolerance of symptoms
C
What is the most common symptom of benign breast disease?
a. Pain
b. Tender lump
c. Change in breast size
d. Discharge
e. Change in menses
Answer: A
Cyclical, non cyclical or mammary
Woman with chronic pelvic pain. All Ix normal. She finally says she does not know if she can cope with
her husband’s physical abuse of her for much longer. Is this form of abuse
a. Easy to treat with counselling once recognised
b. Usually first picked up by physicians
c. Gets better in pregnancy
d. Women/the victims fear being left alone
D
You are seeing a 20 yo in ED who presents within 3 hrs of a sexual assault. In giving her psychological
counselling as to what she can expect you explain that she is likely to experience?
a. Anger and aggression followed by a rapid return to normal function
b. Anger and aggression followed by a long period before full recovery
c. Fear and somatic symptoms followed by a rapid return to normal function
d. Fear and somatic symptoms followed by a long period before full recovery
Answer: D
Anger / Fear / Anxiety & Physical pain then somatic symptoms
Second stage = somatic symptoms
You are asked to assess a woman who was raped 6 hrs ago. Which of the following is least likely?
a. She will develop fear and anxiety with restlessness
b. Somatic symptoms of headaches, fatigue and sleep disturbance
c. Emotional reactions of anger, self-blame and humiliation
d. Those with severe somatic symptoms tend to recover faster
D
.ou examine a woman who has been raped. 24 hrs afterwards her attorney phones to say there was no
sperm or acid phosphatase on the specimens collected. Your reply?
a. You did not want to make a statement anyway
b. Both tests were probably showing false negatives
c. About 1 in 3 rapists have some form of sexual dysfunction
d. The man probably had a vasectomy
B or possibly C
Which of the following scenarios constitutes aggravated criminal sexual assault?
a. Sexual assault where the woman is not the wife
b. Where the penis penetrates the vagina
c. Where consent is not given
d. Where the victim has been coerced by the display or use of a weapon
e. Where force is used
D
The most common cause of injury in women is?
a. Automobile accidents
b. Domestic violence
c. Muggings
d. Rape
e. Athletic injuries
B
The pearl index
a. % become pregnant using a particular contraceptive
b. % do not get pregnant
c. Number of pregnancies / 100 woman years
d. Number of pregnancies / 1000 woman years
C
The most effective post coital contraception is:
a. Ethinyloestrodiol 50mg for 5 days
b. Ethinylestradiol 100mcg and norethisterone 500mcg repeat in 12 hours
c. Provera 10mg for 5 days
d. Danazol 200mg for 5 days
B
Current recommendations are levonorgestrel 0.75mg 12/24 apart or 1.5mg as a single dose (89% of
pregnancies prevented). Other options include Yuzpe regime (E+P) as above (75-80% of pregnancies
prevented, more side effects). Copper IUD within 120 hours of intercourse (90%) and mifepristone 600mg
(100%) were other options. The Cochrane review on the topic discussed Danazol and the five day E
approach and said that they didn’t hold any advantage over Yuzpe. Speroff says danazol is not effective.
Additionally the 5mg E dose is 5mg not 50mg.
You are seeing a rape victim 12 hrs after the event. She is on day 13 of a 28-30 day cycle and wants the
best advice re contraception. The options are:
a. Nothing
b. 10 mg of progesterone for 5 days
c. Oral contraceptive pill for five days
d. Vaginal douching
e. Intrauterine saline wash out
C
Sex 24 hrs ago but condom broke. Which is true?
a. Ethynyl oestradiol plus norgestrel should be given within 96 hrs after unprotected sex
b. Ethynyl oestradiol 5mg/day for 5 days within 96 hrs
c. After 1 unprotected midcycle intercourse, pregnancy rate about 15% can be expected
d. Pregnancy rate after postcoital contraception is about 5%
e. 90% of women after postcoital hormone treatment get withdrawal bleed within 14 days
C and E
Emergency contraception should be used within 72 hours of unprotected intercourse; unprotected
midcycle intercourse is about 20%, although Speroff says 8% after single act of intercourse; pregnancy
rate following emergency contraception is less than 5%; 90% get a period on time or early
What is the concern about the pregnancy after failed morning after pill?
a. Multiple pregnancy
b. Abnormal fetus
c. Increased risk of ectopic
d. Increased risk of miscarriage
e. Higher risk of premature labour
C
Ectopic pregnancies have been reported anecdotally following emergency oral contraception. In theory
progestational agents may inhibit tubal mobility and predispose to ectopic implantation, but none of the
emergency oral contraceptive regimens in use increase the risk. (Speroff).
All effective post-coital contraception except?
a. Yuzpe regime
b. levonorgestrel
c. IUCD
d. RU 486
e. Single dose danazol
E
What is the least correct statement regarding contraception or MAP (they weren’t sure which)
a. RU486 plus misoprostol 400mg oral 48/24 later
b. RU 486 plus misoprostol 800 mg PV 48/24 later
c. Mifepristone had been approved for the use in the USA as contraception (or maybe TOP)
All are correct if the question refers to TOP. If using mifepristone as a morning after pill a single dose of
600mg is effective. It is not licensed as contraception or MAP; only licensed for TOP
Answer: C
Which is most effective contraception?
a. OCP
b. Depot Provera
c. Condoms
B
OCP – 0.1/7.6; depot – 0.3/0.3; condoms – 3.0/13.9; minipill – 0.5/3.0
Failure rate in users of which contraceptive is 1%
a. COCP
b. Depo Provera
c. POP
d. Condoms
B
a. COCP – 8%
b. Depo Provera
c. POP – 8%
d. Condoms – 15%
In typical users, which has a pregnancy rate below 1%?
a. Depot MPA
b. Condoms
c. POP
d. COCP
A
Largest drop out rate in first year of use?
a. Micronor (POP)
b. Norplant
c. Progesterone coated IUD
d. Depo Provera
e. No difference
D
a. Micronor (POP) – 72% continue (same for OCP)
b. Norplant – 85% continue
c. Progesterone coated IUD – 81%
d. Depo Provera – 70% continue
The contraceptive with greatest continuation at one year is:
a. Progesterone only pill
b. Mirena IUCD
c. Depo Provera
d. Norplant / implanon
D
POP – 72% continue (same for OCP)
Norplant – 85% continue
Progesterone coated IUD – 81%
Depo Provera – 70% continue
Regarding contraception. Which is true?
a. Principle action of POP is to suppress ovulation
b. More females using IUD have ectopics than females using no contraception
c. More females with Cu IUD have ectopics than inert IUD
d. Epileptics can’t use OCP
e. Mucus method has Pearl index < or equal to 5 preg/100 years if couple abstain 2 days prior to
ovulation
f. Unilateral tuboovarian abscess is associated with IUD
F
37 yo woman expresses concern about developing ovarian cancer. She took OCP for 1 yr at age 25 and
asks whether the use of OCP’s has increased her risk of ovarian cancer. You explain that?
a. OCP use as described by the patient does not alter the risk of ovarian ca
b. OCP use as described decreased the risk of ovarian cancer
c. OCP use as described offer a protective effect for 5-7 yrs
d. OCP use decreased the risk but only if taken for 3 yrs or longer continuously
e. OCP use does not protect against epithelial tumours
B
The protective effect increases with duration of use and continues for 20 years after stopping the
medication. The protection is seen in women who use it for as little as 3-6 months although use for at
least 3 years is required for a noticeable impact. (Speroff)
Benefits of OCP are all except:
a. Reduce menorrhagia
b. Reduce PID
c. Reduce benign breast disease
d. Reduce ovarian cancer
e. Reduce cervical cancer
E
In regard to the OCP
a. Older women (>35yo) are at increased risk of arterial thromboembolism regardless of whether they smoke
b. The principle action of the POP is to inhibit ovulation
c. Diane 35 is likely to take over as the most frequently used OCP in well asymptomatic young women
d. OCP containing the new progesterones gestodene and desogesteral have been shown to be more effective at preventing pregnancy than the older formulations
e. Phenytoin does not affect the efficacy of 30-35 microgram OCP formulations
A
d. OCP containing the new progesterones gestodene and desogesteral have been shown to be more effective at preventing pregnancy than the older formulations side effect profile better only
An 18 yo epileptic comes to you requesting OCP. She is on phenytoin. You would prescribe:
a. 30 ug OCP formulation
b. 50 ug OCP formulation
c. POP
d. IUCD
e. Barrier methods
B
17 yo presents with vaginal spotting. She is sexually active and has been on OCP for 1 yr without trouble.
What do you do?
a. Increase E dosage of OCP
b. Increase P dosage of OCP
c. Ask her to come in to do a swab for Chlamydia
d. Give her a 1 week course of ?E with the OCP too
C
Woman who constantly forgets to take oral contraceptive pill. You should:
a. Consider she has dementia praecox…(it would improve on oestrogen Rx)
b. Consider she has covert intentions
c. Change her from the 28 days pill
d. Consider she secretly desire pregnancy
e. Consider she has hidden guilt regarding contraception as a bad thing
C
Progesterone only pills work by all except?
a. thickens cervical mucus
b. sperm toxicity
c. inhibits ovum transport
d. inhibits ovulation
e. endometrial atrophy
B
After Depo Provera usage number of women who conceive after 15 months?
a. 90%
b. 75%
c. 50%
d. 25%
A
90% by 18 months (Speroff)
12/12 = 78% ( FPA)
18/12 = all
Depo Provera is noted for all except:
a. Useful for those on phenytoin
b. No increased risk of VTE
c. No change in menstrual pattern
C
Which of the following is not true of depo provera
a. Has no significant effect on lactation
b. Is safe during lactation
c. Does not cause troublesome PV bleeding
d. Is effective contraception for a patient with epilepsy
C
LEAST TRUE depot
a. Causes bone loss
b. Amenorrhoea 50% at 12 months
c. Amenorrhoea 95% at 24 months
d. CI in breastfeeding
D
What is the cumulative pregnancy rate of a woman using norplant for 5 yrs?
a. <1%
b. 1%
c. 3%
d. 5%
e. 8%
0.2% per year (Speroff)
Answer: B
Who is most likely to have an ectopic pregnancy. One who conceives while using?
a. condoms
b. diaphragm
c. minipill
d. OCP
e. No contraception
?C
Absolute rate without contraception would be higher
Risk of ectopic highest with?
a. COCP
b. Condoms
c. No contraception
d. POP
e. Diaphragm
C
A 25yo P2 has an IUCD for contraception. She developed increasing dysmenorrhoea and heavier
menstrual periods. Management:
a. commence NSAIDS
b. removal of IUCD
c. removal of IUCD and start antibiotics
d. removal of IUCD and perform laparoscopy
e. removal of IUCD and perform hysteroscopy
A
IUCD (copper)?
a. increased PID with increased use
b. increased PID in multiparas
c. increased unilateral tuboovarian infection
d. copper virtually eliminates actinomycoses
e. treat uncomplicated actinomycoses
C
Increased risk of PID around time of use; rate of actinomyces is much lower with copper IUD (less than 1%) but still higher than LNG IUD.
Regarding contraception?
a. The risk of PID increases with the duration of use of an IUD
b. Unilateral tubo-ovarian abscess is more common when an IUD is insitu
c. A copper containing IUD rapidly loses efficacy after 2 yrs as the copper is degraded
d. An IUD should not be removed in the event of a pregnancy as removing it may cause miscarriage
e. The natural family planning method in which ovulation is predicted by the presence of cervical and vaginal fluid has a Pearl index of < 5 pregnancies per year providing abstinence
commences at least 2 days prior to ovulation
B
A pearl index of <5 is unlikely for natural methods
Actinomycosis on routine Pap with IUCD in situ. Management?
a. Remove the IUCD
b. Give antibiotics
c. Remove the IUCD and give penicillin
d. Repeat the smear
D
UTD suggests that if the patient is asymptomatic the finding may reflect colonisation rather than infection and in this situation there is no evidence for ABx or removal.
A patient presents after a Pap smear showing Actinomycoses on Gram stain. Your immediate
management plan would include.
a. Treat with antibiotics with the IUCD in situ
b. Remove the IUCD and resmear in 3 months
c. Repeat the Pap smear
d. Remove the IUCD and treat with antibiotics
e. Reassure the patient
E
Patient has IUCD for 2 yrs and now actinomycosis detected on routine pap smear. Pelvic exam was normal. What is the next most appropriate treatment?
a. Leave IUCD in, treat with penicillin
b. Remove IUCD, treat with penicillin for 2 weeks and then reinsert another IUCD
c. Remove IUCD, treat with oral penicillin for 2 weeks. IUCD contraindicated in future
d. Remove IUCD, treat and no further treatment required
e. No treatment needed if asymptomatic
E
Pelvic actinomycosis infection
a. Should be treated with streptomycin
b. Is a Gram negative fungus
c. Is usually R sided
d. May occur secondary to uterine colonisation which occurs with 5% of plastic IUD users
A
Actinomyces is found in up to 30% of plastic IUD users; is a gram positive bacilli and should be treated
with oral penicillin although tetracycline can be used.
In a woman who is 8 weeks pregnant with an IUD in situ the correct management is?
a. Immediate removal of the IUD
b. Advise termination of pregnancy
c. Remove the IUD only if there is evidence of infection
d. If the strings are visible cut them as high up in the cervical canal as possible
e. Immediate laparoscopy to exclude ectopic pregnancy
A
In a woman who conceives with an IUD inset, all of the following are associated EXCEPT:
a. Miscarriage
b. Prematurity
c. Low birth weight
d. Fetal abnormalities
e. Chorioamnionitis
D
Tubal sterilisation (diathermy) risk of failure per 1000?
a. 0.1
b. 0.7
c. 3
d. 7
D
(Speroff – 0.75% 10 year cumulative failure rate)
7.5/1000 unipolar 24.8/1000 Bipolar 10 yr cumulative (NOVAKS)
G3P3 had TL. Presents with ectopic in one tube. Mx?
a. bilateral salpingectomy
b. salpingostomy
c. reclip tubes after removing ectopic
A
The most common emotional response after a termination is
a. severe depression
b. shame
c. relief
d. anxiety
e. psychosis
C
After which procedure is the decay rate of BHCG the fastest?
a. Vacuum curette for termination of pregnancy
b. Vacuum curette for spontaneous abortion
c. Resection of ectopic pregnancy
d. Linear salpingotomy for ectopic pregnancy
e. BHCG decays at the same rate for all procedures
E
What is the smallest fetal pole that a competent ultrasonologist would confidently diagnose as nonviable
due to absence of cardiac activity?
a. 5 mm
b. 9mm
c. 13mm
d. 17mm
e. 21mm
B
What is the smallest fetal sac size that a competent ultrasonologist would confidently diagnose as a
blighted ovum because of lack of fetal pole?
a. 11mm
b. 15mm
c. 19mm
d. 23mm
e. 27mm
D
When no live fetus is visible in a gestation sac and the mean sac diameter is 2.0cm or greater (ASUM)
Patient presents 6 weeks pregnant. PVB and pain. US live IU pregnancy. Normal FH. Chance of ongoing
pregnancy?
a. 90%
b. 70%
c. 50%
d. 30%
e. 10%
A
90-96% with FHB at 7-11/40 do not miscarry
Threatened miscarriage at 6 weeks shows cardiac activity and appropriate for dates. Risk of miscarriage?
a. <10%
b. 50%
c. 25%
d. 90%
A
Least valuable predictor of missed abortion
a. 5mm sac with no heart beat
b. 15 mm sac with no fetal pole
c. 20 mm sac and no fetal heart beat
A
A patient is 16 days late for her period and BHCG is 140,000. The most likely diagnosis is?
a. Multiple pregnancy
b. Molar pregnancy
c. Miscarriage
d. Ectopic pregnancy
e. Gestational trophoblastic disease
UTD states that HCG > 100 000 in early pregnancy is strongly suggestive of molar pregnancy
Answer: A – twins are more common
A woman is 6 weeks late for her period and her BHCG was noted to be 140,000 mIU/ml. The most likely
diagnosis is:
a. Single IU pregnancy
b. Tubal ectopic pregnancy
c. IU pregnancy anddysgerminoma
d. Multiple pregnancy
e. Ovarian pregnancy
A
Percentage of chromosomal abnormalities in 1st trimester spontaneous miscarriage?
a. 20%
b. 30%
c. 40%
d. 50%
e. 60%
D
50% of all 1st trimester losses, 30% of 2nd trimester losses and 3% of stillbirths are karyotypically
abnormal. (Speroff
Spontaneous ab, correct option:
a. Increased in women > 40
b. DES associated with many pregnancy problems but not with spontaneous miscarriage
c. Most common chromosomal abnormality is triploidy
d. Genetic abnormality in aborted fetuses are similar to those occurring in term fetuses
A
A 28 yo has had 2 miscarriages 8w and 10w and presents for advice:
a. She should be labelled recurrent miscarriage
b. She does not warrant pre-conception counselling
c. If one more miscarriage then chance of livebirth <6%
d. Chance of another miscarriage = 40%
e. 50-60 % spontaneous abortuses are chromosomally abnormal
E
After one miscarriage – 14-21% chance; two – 24-29%; three – 31-33% (UTD)
Miscarriage at 18/40 but 12/40 size, best Rx?
a. nothing
b. suction curettage
c. prostaglandins
d. intra amniotic saline/PG
B
A woman had 3 consecutive first trimester miscarriages. What is the likelihood of miscarriage in the next
pregnancy?
a. 5%
b. 10%
c. 30%
d. 50%
e. 70%
C
If one previous liveborn infant – 32%; if no previous liveborn infants – 40-45%
What is the percentage of patients with recurrent miscarriage that have chromosome abnormality?
a. 1%
b. 3%
c. 10%
d. 30%
e. 50%
B
The incidence of chromosomal abnormalities in this group is 2.9% (UTD). 50% balanced reciprocal
translocation, 25% Robertsonian translocation and 10% sex chromosome mosaicism in females
One partner of a couple with recurrent miscarriage has a balanced reciprocal translocation – the most
correct is:
a. Phenotypically normal offspring in 50% of conceptions
b. Major anomalies with trisomy in 25%
c. Phenotypically normal in 10% if husband has translocation
d. Phenotypically normal in 70% if mother has translocation
e. All offspring will have a balanced translocation
A
Theoretically - 25% of gametes should be normal, 25% abnormal but balanced; this yields 50% chance of a
normal pregnancy (normal or balanced) and 50% chance of abnormal (miscarriage or anomalous fetus). If
Robertsonian (questions above is reciprocal) – 1/6 normal, 1/6 abnormal but balanced, 2/3 abnormal and
unbalanced; this yields 33% chance of normal pregnancy and 67% of abnormal pregnancy. (Speroff) There
is a parental sex influence with the risk for unbalanced progeny higher if the female parent carries the
gene (C&R). If diagnosed after the birth of an abnormal child they have a 5-30% chance of having a
liveborn offspring with unbalanced chromosomes as compared to 5% risk is carriers identified for other
reasons. (Williams)
Patient with a history of recurrent abortion now 6-7 weeks pregnant. Investigation performed in past
could reveal no cause for recurrent Abs. Management:
a. Progesterone until 28 weeks
b. Anti-prostaglandins
c. Serial hCG measurements
d. Pelvic USS
e. Reassurance
D
A woman with 4 previous 1st trimester miscarriages has been fully investigated and no cause found.
Management in next pregnancy?
a. Progesterone supplement empirically or test serum progesterone levels
b. Aspirin and heparin
c. Serial BhCG
d. US at 6/40
D
37 yo with recurrent miscarriage. Most likely diagnosis is
a. Obstetric Lupus
b. Luteal phase deficiency
c. Uterine anomaly
d. Idiopathic
D
Acquired and congenital uterine abnormalities are responsible for 10-50% of RPL. Congenital uterine abnormalities are present in 10-15% of women with RPL. Luteal phase defects are present in up to 25%,
APLS in 5-15%. No cause is found in 50%
Recurrent miscarriage x 4. Most likely cause?
a. lupus
b. idiopathic
c. chromosomal abnormalities in parents
B
Patient has had 3rd miscarriage and karyotype on products was abnormal. What is the most likely
abnormality?**
a. Autosomal trisomy
b. Triploidy
c. Chromosomal translocation
d. Sex chromosome abnormality
A
Autosomal trisomies > monsomy X > polyploidies. In women with recurrent pregnancy loss the karyotype
is more likely to be normal, especially under the age of 35. If the karyotype is abnormal it follows the
same pattern as seen in the general population. (Speroff)
A woman who is G3P0 with 3 previous miscarriages all requiring D&C. After the last D&C she developed 6
months of irregular light menstrual periods. Hysterosalpinogram was performed. Which of the following
likely to be? (4 HSG’s were shown)
a. T-shaped uterus after DES exposure
b. Bicornuate uterus
c. Single IU filling defect – endometrial polyp/fibroid
d. Multiple IU synechiae
D
What is the most common chromosomal abnormality found in abortuses?
a. Trisomy 16
b. Trisomy 21
c. 45, X
d. Trisomy 18
e. XXXX
?C
Chromosomal abnormalities account for approximately 50% of miscarriages; increased at earlier gestations. Breakdown is – autosomal trisomies 52%, monosomy X 19%, polyploides 22% and others 7%.
Trisomy 16 is the most common autosomal trisomy (UTD). Does XO have > than trisomy 16? - No
.A woman has LNMP 7w ago, pv bleeding. bhCG positive and TVUS 7w viable fetus and left adnexal mass.
Laparoscopy revealed a haemorrhagic CL. Which of the following is correct?
a. oral oestrogen
b. oral progesterone
c. IM depot progesterone
d. IM hCG
e. No hormone needed
E
At 12 weeks gestation the corpus luteum is removed for bleeding, the most appropriate pregnancy
support with the least fetal risk is:
a. Duphaston
b. Depo Provera
c. Norethisterone
d. Progesterone and oestrogen
e. No hormones
E
What is of proven value as treatment for recurrent 2nd trimester miscarriages associated with uterine
contractions?
a. Erythromycin
b. Transfusing wife with husbands WBC
c. Strassmann operations
d. McDonald cerclage
C
TOP at 6w. One week later, no bleeding or pain but BHCG remains positive. There is a 6-7 week size
uterus. The path showed scanty decidual tissue, no fetal parts. Next?
a. Qualitative BHCG
b. Ultrasound
c. Repeat curette
d. Laparotomy
B
.At 7 weeks gestation, which of the following findings is most likely to be consistent with a tubal ectopic
pregnancy?
a. Abdo US empty uterus + BHCG <600
b. Abdo US empty uterus + BHCG <1000
c. Abdo US empty uterus + BHCG >7000
d. Abdo pain and negative culdocentesis
C
A woman presents with abdominal pain and vaginal spotting at 6 weeks amenorrhoea, βhCG is 6000, US
empty uterus. O/E tender adnexa. Best next step:
a. Serial BCHG
b. Rpt US in 1 week
c. Laparoscopy
d. Laparotomy
C
6/52 pregnant, 3 days of abdo pain and 2 days of PV bleeding. Bilateral adnexal tenderness. US –
complex adnexal mass and free fluid in POD. Next?
a. Culdocentesis
b. Laparotomy
c. Quantitative BHCG
d. Laparoscopy
D
Regarding ectopic pregnancy:
a. Continuing US and BHCG delays intervention and leads to greater risk of rupture
b. Recurrence risk about 10%
c. Better chance of subsequent live birth with salpingostomy vs salpingectomy
B
Recurrence risk 10-27% (Speroff)
Ectopic pregnancy
a. Increased after legal TOP
b. Increased on progesterone only pill more than without contraception
c. Rate is higher with copper IUD’s than plastic ones
d. Increased with IUD more than normal population
e. None of the above
E
Woman at 6/52 amenorrhoea with PV bleeding and lower abdominal pain. HCG 3000 and US empty
uterus. Options?
a. Do nothing
b. Serial HCG
c. Laparoscopy
C
A G1 P0 woman with an ectopic pregnancy. At laparotomy, the right tube is found to be bound down with
adhesions. There is a 1 cm bluish fimbrial mass on the left tube. Best option.
a. Salpingectomy and repair of the other tube.
b. Fimriectomy
c. Milk the lesion from the tube.
d. Methotrexate
?D
Ideal management would be salpingostomy and later laparoscopy and dye studies +/- dye studies. Is
finbriectomy an appropriate substitute, or milking lesion or MTX?
A lady 12 weeks pregnant with a bicornuate uterus presents to A&E with pain and bleeding. US shows an empty uterus and 8 cm adnexal mass. Obs BP 90/60, PR 110:
a. Get A&E to organise laparoscopy with probable salpingostomy
b. Get A&E to organise laparoscopy with probable laparotomy
c. Do nothing until you arrive in 30 mins
d. Have a culdotomy tray ready for you
B
12 weeks pregnant. HCG positive at 6 weeks. No other antenatal care. Feels pregnant. One-week history
of PCB without cramping. Speculum reveals bright red 3 cm mass on the ectocervix. Which test will give a
definite diagnosis?
a. Real time US
b. Tissue biopsy
c. Colposcopy and biopsy
d. Stain with Lugold’s iodine
A
A routine obstetric ultrasound showed a viable singleton fetus outside the uterine cavity with
measurements consistent with 18/40. No fetal abnormality detected. What is appropriate Mx?
i. Expectant management
ii. Wait until fetal viability, deliver electively and remove the placenta
iii. Wait until fetal viability, deliver electively
iv. Immediate delivery of fetus only
v. Immediate delivery of fetus and placenta
iv
If T1 – operative scope is an option.
Even if advanced gestation – do IMMEDIATE interruption.
Leave placenta behind
Do CS and find an unanticipated abdominal pregnancy with placenta involving left broad ligament and sigmoid. Management:
a. Attempt to remove all placenta doing colostomy
b. Remove as much of the placenta as you can
c. Leave placenta behind
C
A patient presented to casualty: 8 weeks of amenorrhoea with vaginal bleeding. Pelvic US by LMO showed
numerous small, cystic and fluid containing spaces in the uterus with characteristic “snowstorm”
appearance and no fetus detected. Histology showed hydropic degeneration, swelling of the villous
stroma and abundant avascular villi. Which of the following is correct?
a. it is not associated with choriocarcinoma
b. karyotypically is either 69XXY and 69XYY
c. chromosomal composition completely of paternal origin
d. it has a chromosomal pattern of 69XXX or 46XX
C
These histological findings are consistent with a complete molar pregnancy. Choriocarcinoma usually
doesn’t have villi (Robbins) but the findings above can be associated with choriocarcinoma. It has a
normal karyotype (46 XX) but both chromosomes are derived from paternal origin. Partial moles are
usually triploid.
The most common presenting symptom of molar pregnancy is:
a. Abnormal bleeding
b. Hyperemesis
c. Larger than expected fundus
d. Thyrotoxicosis
e. Pre-eclampsia
A
Concerning partial moles, all true except:
a. Fetus may be alive
b. Mostly triploidy
c. Same follow up as complete moles
d. More often go on to choriocarcinoma than complete moles
e. Preeclampsia occurs most commonly with partial moles
Answer: D (most incorrect although C and D aren’t correct either)
Hydatidiform mole – which is correct?
a. Choriocarcinoma can be associated with hyperthyroidism
b. Incidence decreases after age 40
c. Rhesus blood group is prognostic indicator
d. Persistent in <5%
A
Choriocoarcinoma can be associated with hyperthyroidism, incidence increases with increasing maternal
age, Rh is not a prognostic factor and persistence occurs in 15%
Regarding hydatidiform mole, which statement is correct:
a. <3 % progress to choriocarcinoma
b. Choriocarcinoma can be associated with thyrotoxicosis
c. Commonest karyotype is 45 XO
d. Association between prognosis and rhesus blood group
e. Less common in older women
B
Choriocarcinoma occurs following 2.5% of molar pregnancies; usually 46XX karyotype, not association
with blood group, commoner in older women
A 30yo lady, diagnosed to have hydatidiform mole at 14 weeks amenorrhoea, which of the following is the
management of choice?
a. suction curette
b. sharp curette
c. hysterectomy
d. methotrexate
e. hysterectomy
A
32 yo G2P2 with molar pregnancy. Fundal height 28 weeks. Best method of evacuation?
a. IOL
b. abdominal hysterotomy
c. Suction curettage
d. D&C
e. TAH
C
Treatment of non metastatic gestational trophoblastic tumour in a 21yo who had D&C 8 weeks earlier is:
a. single agent chemotherapy
b. multi agent chemotherapy
c. radiotherapy
d. hysterectomy
e. D&C
A
Patient presents 4 months after a term delivery with daily pv bleeding. Serum bhCG 104,000IU. CXR shows
multiple opacities. CT head and abdo normal. LFTs normal. Management:
a. methotrexate
b. hysterectomy to debulk disease
c. suction curette
d. combined chemotherapy
e. lumbar puncture
E
Patients with hyperthyroidism with trophoblastic tumours have?
a. High total T4 +T3
b. High free T4 + T3
c. Decrease TSH
d. All of the above
D
Who is less likely to have high concentrations of lactobacillus in vaginal flora?**
a. Neonate
b. Premenopausal
c. Postmenopausal
d. Pregnant
e. Non-pregnant reproductive age
C
The percentage of woman who experience at least one episode of vaginal candidiasis in their reproductive
years:
a. 20%
b. 35%
c. 50%
d. 70%
e. 90%
D
75% by menopause (UTD), and 45% have > 2 episodes
Regarding candida?
a. ketoconazole is safe in pregnancy
b. typical thrush spots seen in 20% candida vaginitis
c. antifungal treatment to vulva reliably eradicates candida vulvitis
d. low oestrogen favours candida
e. diabetics are prone to candida and often present with it prior to diagnosis of DM
E
Occurs in increased oestrogen states; ketoconazole is contra-indicated in pregnancy
Which of the following is not an acceptable treatment for Candida vulvovaginitis?
a. Ketoconazole
b. Fluconazole
c. Itraconazole
d. Terazole
C
The most common sexually transmitted disease in Australia?
a. Gonorrhoea
b. Chlamydia
c. Syphilis
d. HSV 1
e. HSV 2
E
Herpes –which is wrong?
a. HSV1 confers some protection against HSV2
b. HSV2 generally affects genitals
c. Most have recurrence within 6 months of primary attack
d. Acyclovir with primary infection reduces no & severity of recurrences
D
HSV, all true except:
a. HSV1 offers some protection against HSV 2
b. HSV 2 > genital infection than HSV 1
c. Acyclovir for acute attack decreases recurrences
d. HSV 2 most recur in 6 months
e. Women with cervical cancer have increased incidence of HSV
C
What is the most common organism to cause septic shock in gynaecology?
a. E. coli
b. Bacteroides
c. Beta haemolytic Streptococci
d. Staphylococcus
e. Clostridium
A
12 hrs after a TAH + BSO a patient developed a temperature of 39.4 degrees, tachycardia and BP 90/50. A
diagnosis of septic shock was made. The most likely organism is:
a. E.coli
b. Clostridium
c. Bacteroides
d. GBS
e. S. Aureus
A
Necrotising fasciitis caused by all except
a. Staph
b. Proteus
c. Bacteroides
d. E. Coli
e. Clostridium
B
All of the following are the characteristics of toxic shock syndrome except?
a. temp > 39C
b. multi-system involvement
c. S aureus in blood culture
d. Diffuse erythematous rash
e. S aureus on vaginal swab
C
80-90% of patients have S.Aureus isolated from wound or mucosal sites whilst only 5% will have S.Aureus
isolated on blood cultures
For Bacteroides fragilis the least effective antibiotic is
a. Cefotaxime
b. Clindamycin
c. Chloramphenicol
d. Gentamicin
e. Metronidazole
D
An anaerobic, gram-negative bacillus that is sensitive to metronidazole and clindamycin. Gentamicin
offers gram-negative cover. Chloramphenicol and cefotaxime cover bacteroides fragilis.
What organism will metronidazole and gentamicin not cover?
a. Gram positive aerobe
b. Gram positive anaerobe
c. Gram negative aerobe
d. Gram negative anaerobe
e. Trichomonas
A
Of following antibiotics the one not recommended as a first line agent of choice for UTI in young children
is?
a. Sulfonamide
b. Nitrofurantoin
c. Trimethoprim
d. Amoxicillin
e. Cephalosporins
B
A 38yo woman with ph of chronic PID presents to you with increasing pelvic pain, unwell, rigors. Temp 40
degrees, HR 100. VE: 8cm tender mass protruding onto upper half of rectovaginal septum in midline. WCC
24,000. Diagnosis of pelvic abscess made. Which is correct?
a. colpotomy and drainage of abscess and antibiotics
b. TAH, BSO and ABx
c. Abdominal drainage of abscess and ABx
d. Conservative treatment with iv ABx
A
Now laparoscopic drainage may be the appropriate answer. Either colpotomy or laparotomy are
reasonable. Colpotomy if access is easy
Regarding tubo-ovarian abscess?
a. Can be visualised by US
b. Causes eosinophilia
c. Positive Chlamydia on cervical swab
d. Associated with leucopenia
A
The organism most likely to be grown from culture of a tubo-ovarian complex is:
a. Group D enterococci
b. Mixed anaerobes
c. Neisseria gonorrhoea
d. Chlamydia trachomatis
e. Escherichia coli
B
PID with temp. 39 degrees and bilateral pelvic tenderness. Chlamydia on swabs. Best therapy:
a. IM Cephalothin and PO doxy
b. PO doxy alone
c. IV cefoxitin and PO doxy
d. IV clindamycin
e. IV penicillin + erythromycin
C
A 27 yr old lady with a diagnosis of PID. She was treated with oral doxycycline. After 3 days there was no
improvement. A 8cm swelling was found on ultrasound in POD. What is the appropriate management?
a. Laparoscopy
b. Laparotomy
c. Culdotomy
d. Change to IV cefotaxime plus oral doxycycline
e. Transvaginal ultrasound guided aspiration
D
Probably OK to trial medical management first but probably will need surgical drainage, definitely if signs
of rupture or if systemically unwell.
A woman at 8w is diagnosed with Chlamydia on endocervical swab. The appropriate management would
be:
a. no treatment needed
b. oral doxycycline
c. oral erythromycin
d. oral penicillin
e. no treatment needed now but repeat swabs at 28w
C
The optimal treatment for chlamydia is azithromycin 1gm orally once or doxycycline 100mg BD for 7 days.
Given that the patient is pregnant the treatment would be erythromycin although a Cochrane review
suggests that amoxycillin is better tolerated and just as effective.
26 yo at 26 weeks gestation with PV discharge and Chlamydia on swab?
a. penicillin
b. cephalosporin
c. doxycycline
d. erythromycin
e. metronidazole
D
The optimal treatment for chlamydia is azithromycin 1gm orally once or doxycycline 100mg BD for 7 days.
Given that the patient is pregnant the treatment would be erythromycin although a Cochrane review
suggests that amoxycillin is better tolerated and just as effective.
Which of the following is most likely to be associated with offensive post coital discharge?
a. Chlamydia
b. Gonorrhoea
c. Gardnerella
d. Candidiasis
e. HPV
C
Chlamydia:
a. Cervix usually looks irritated or inflamed
b. Incidence <1% in antenatal, family planning or general gynae population
c. If low incidence population, Microtrac false +ve ~ 50%
d. Cefoxitin/metronidazole is adequate treatment
e. At first infection 50% of women have symptomatic salpingitis
C
Chlamydia:
a. Is in <1% of O&G and FPA clinics
b. Diagnosis is by posterior vaginal fornix swab
c. Cervix usually looks abnormal
d. In a low risk population has a 50% PPV on ELISA
e. Treatment is with cefoxitin and Flagyl
f. 50% will clinically develop PID
D
D
Although the S&S of testing for chlamydia is 95% inhigh risk populations it falls significantly in lower risk
populations (less than 75%)
16 yo woman presents asking for an STD check. Partner recently diagnosed with NGU, most appropriate
management?
a. Cervical swabs and review
b. Doxycycline bd for 10/7
c. Cervical swabs and oral doxycycline for 10 days
d. Counsel and test for HIV
C
A 24 yo not sexually active woman presents with a history of an intermittent white vaginal discharge, is
not pruritic, the pH is less than 0.45.
a. Candidiasis
b. Trichomonas
c. Gardnerella
d. Physiological vaginal discharge
D
A woman with known Gardnerella vaginal infection is to have a vaginal hysterectomy. Which antibiotic
would be most cost effective for pre-op prophylaxis?
a. Ceftriaxone
b. Piperacillin
c. Cephazolin
d. Chloramphenicol
e. Clindamycin and gentamicin
E
Best options would be metronidazole, tinidazole or clindamycin
Sexually active 27 yo has 2/52 history of urgency and dysuria. Came to casualty, MSU collected and
commence on Keflex. There was no growth on the MSU. Her symptoms persist. Next?
a. Repeat MSU
b. Quantitative analysis of urine WBC’s
c. Uretheroscopy
d. Chlamydia swabs of urethra and cervix
D
A 37 yo woman, previous TAH for micro-invasive Ca cervix. Thinks the man she slept with 2 weeks ago has
developed gonorrhoea. Best way to establish the diagnosis?
a. Culture urethra
b. Culture vaginal vault
c. Culture rectum
d. Gram stain of vaginal secretions
e. Gonozyme assay
A
With respect to Actinomyces, which is incorrect
a. Causes toxic shock syndrome
b. Can be detected on Pap smear
c. Is associated with IUD
d. Can be treated with IM penicillin
A
A Somali woman presents for a routine pelvic exam. While doing the pap smear you notice a cluster of
small vesicles of her right buttock. She says she has had this problem on and off over several years. the
likely diagnosis is:**
a. Condyloma lata
b. Herpes (HSV2)
c. Eczema
B
Which of the following combinations is correct?
a. Syphilis is satisfactorily treated with erythromycin
b. Ampicillin to treat PID
c. Lindane to treat molluscum contagiosum
d. Tetracycline to treat LGV (Lymphogranulosum venereum) patient newly migrated to Australia
e. Sulphonamide to treat granuloma inguinale
D
Syphilis is treated with penicillin, PID is treated with multiple antibiotics, molluscum contagiosum resolves
spontaneously, granuloma inguinale (Donovanosis) is treated with azithromycin
Which combination is correct?
a. erythromycin – syphilis in pregnancy
b. penicillin/ampicillin for teenager with PID
c. tetracycline for recent migrant with LGV
d. lindane for molluscum contagiosum
D
Which viral class does Molluscum Contagiosum belong to
a. Pox virus
b. Herpes virus
c. Adenovirus
d. Papilloma virus
A
What organism causes Donavanosis?
a. Gardenerella vaginalis
b. Chlamydia trachomatis
c. Corynebactium donavoneias
d. Haemophilus ducreyi
e. Calymmatobacterium granulomatis
E
Gardenerella vaginalis causes bacterial vaginosus, chlamydia trachomatis causes lymphogranuloma
venereum, corynebacterium donavoneias (made up), haemophylis ducreyii causes chancroid and
calymmatobacterium granulomatis (Klebsiella granulomatis / granuloma inguinale) causes donovanosis.
Treat with azithromycin.
What organism causes Chancroid
a. Gardenerella vaginalis
b. Chlamydia trachomatis
c. Corynebacterium donavoneias
d. Haemophilus ducreyi
e. Calymmatobacterium granlumatis
D
Gardenerella vaginalis causes bacterial vaginosus, chlamydia trachomatis causes lymphogranuloma
venereum, corynebacterium donavoneias (made up), haemophylis ducreyii causes chancroid and
calymmatobacterium granulomatis (Klebsiella granulomatis / granuloma inguinale) causes donovanosis.
Treat with azithromycin.
Which organism causes Lymphogranuloma venereum?
a. Calymmatobacterium granulomatis
b. Haemophilus ducreyi
c. Gardnerella vaginalis
d. Chlamydia trachomatis
e. Calymmatobacterium donovae
D
Calymmatobacterium granulomatis - donovanosis; Haemophilus ducreyi – chancre; gardnerella vaginalis –
BV; chlamydia trachomatis – lymphogranuloma venereum; calymmatobacterium donovae – made up.
Treat with doxycycline or azithromycin.
Regarding pelvic tuberculosis:
a. Its origin is usually bovine
b. First line treatment is streptomycin
c. It affects the tubes more often than the uterus
C
Fallopian tube and endometrium are the two commonest sites of infection
Female with painless vulval ulcer, 1 cm, indurated base. Definitive/first Ix?
a. TPHA
b. Dark field illumination
c. VDRL
d. Herpes immuno fluorescence
A vs B
VDRL has poor sensitivity in primary syphilis (60-87%), dark field microscopy is better (70-95%) but is
operator dependent, TPHA is probably the best. These days PCR swap for treponema would be ideal
A 20 yo Aboriginal woman presents with 3/52 of a labial ulcer – painless, firm, indurated: also has inguinal
lymphadenopathy. RPR 1/64, TPHA – pos, FTA-Abs – pos, Darkfield microscopy – neg. What is the most
likely diagnosis?
a. Primary syphilis
b. Secondary syphilis
c. Chancroid
d. Donovanosis
A
Syphilitic ulcers last up to six weeks and are associated with lymphadenopathy. Chancroid is painful; donovanosis essentially requires biopsy.
Which true about syphilis?
a. VDRL is a specific Ab for syphilis
b. Condyloma of secondary syphilis is not sexually transmitted
c. Tertiary syphilis require weeks of penicillin
C
Condyloma lata are caused by:
a. HSV 1
b. HPV
c. Treponema pallidum
d. Haemophilus ducreyii
e. Chlamydia
C
Condyloma lata are caused by syphilis (treponema pallidum). HSV 1 causes cold sores, HPV causes genital
warts (condyloma accuminata), haemophilus dureyii causes chancroid.
Appropriate treatment for secondary syphilis?
a. Benzathine penicillin IM x1
b. Procaine penicillin IV x1
c. Cefoxitin
d. Doxycycline
A
The most effective management strategy in the treatment of somatization disorders is?
a. Strict limits on the duration and number of early appointments
b. Mandatory psychiatric referral
c. An exhaustive battery of complex, expensive and invasive investigations to rule out organic
disease
d. Treatment of the somatic symptoms including any analgesia required
e. Negotiate to reduce the symptoms without promising a cure
E
The best treatment for premature ejaculation is?
a. Sensate focus
b. Kegel exercises
c. Squeeze technique
d. Bridge manoeuvre
e. Tranquillisers
C
21 yo G0P0 comes for contraceptives. Had in utero DES exposure. VE -> small cervix, flush with vaginal
fornices, and anterior cervicovaginal ridge. Best Mx of DES exposed patient?
a. Patients with adenosis should be treated with CO2 laser
b. Need a pap smear every 6/12
c. The CO2 laser is the most appropriate Rx of high grade CIN in DES exposed patients
d. DES patients are increased risk of infertility
D
– Every 12/12 with COLP (cervix and vagina), continue
indefinitely. Manage by Gynae Onc
60 yo who took DES in 2 pregnancies for 4 months. What to advise her – all except?
a. She has increased risk of breast cancer
b. Her daughter age 30 has 1% chance of clear cell cancer and risk increased with age
c. Her son might have abnormalities of the reproductive tract
d. Her daughter may have fertility problems related to abnormal uterus
B
Small increased risk of breast cancer in women who took DES; 1:1000-2000 risk of clear cell cancer in
women exposed in utero; fertility problems due to uterine malformations occur; males to have increased
risk of genitourinary abnormalities if exposed.
A 55 year-old woman seeks your advice regarding exposure to DES. She used DES during both of her
pregnancies. All of the following statements are true except:
a. Her daughter has an increased risk of infertility
b. Her daughter has an increased risk of developing clear cell CA of the vagina
c. Her daughter has an increased risk of cervical dysplasia
d. Her son has an increased risk of genital tract abnormalities
e. She has an increased risk of breast cancer
Answer: C (although technically all are true)
A 55yr old woman seeks advice regarding exposure to DES. She used DES during both her pregnancies.
She has a 30year old daughter and a 25year old son. All of the following are correct except
a. Her daughter has an increased risk of infertility
b. Her daughter has an 1% risk of developing clear cell Ca of vagina
c. Her daughter has increased risk of CIN and VAIN
d. Her son has increased risk of genital tract abnormalities
e. She has an increased risk of breast Ca
B
Two fold increase risk of CIN
Progesterone in premenstrual tension?
a. Rx corpus luteal defect
b. Placebo effect
B
Speroff states the progesterone is no better than placebo
Which is not required for a diagnosis of PMS
a. Symptoms consistent with the diagnosis
b. There is a luteal phase pattern
c. Symptoms cause a disruption to her life
d. There are objective findings to support the diagnosis
D
Least common symptom of PMS
a. Bloating
b. Breast tenderness
c. Headache
d. Increased appetite
e. Urinary frequency
E
Which of the following is correct in regard to premenstrual syndrome?
a. It is due to low progesterone level
b. Bromocriptine is more effective than cyclical synthetic progesterone in treating PMS
c. Cyclical progesterone showed no advantage over placebo in treating PMS
d. It is due directly to endogenous endorphin withdrawal
e. It is related to HLA B27 typing
C
Which of the following have been proven more effective than placebo in treatment of premenstrual
dysphoria?
a. Combined oral contraceptive
b. Progesterone pessaries
c. Synthetic oestrogens
d. Micronised oral progesterone
e. Serotonergic antidepressants
E
The most common sexual dysfunction in women is?
a. Stress
b. Depression
c. Guilt
d. Lack of knowledge
e. Gender identity
A
What is the most common cause of dyspareunia?
a. Endometriosis
b. Lack of lubrication
c. Adenomyosis
d. Vulvovaginitis
e. PID
B
The leading cause in women under the age of 50 is localized vulvodynia. In women over the age of 50,
urogenital atrophy is the leading cause of sexual dysfunction.
Introital dyspareunia. Common cause
a. Thrush
b. Inadequate arousal
c. Psychosexual issues
B
A 27 yo woman presents with increasing dyspareunia. She has a past history of ‘woman’s infections” but
cannot remember if these were treated with topical or systemic therapy. The situation is becoming an
increasing source of frustration to her and her husband, but both are mutually supportive. Pelvic examination reveals only mild unilateral adnexal tenderness. Next step?
a. Diagnostic laparoscopy
b. Relaxation therapy to reduce the anxiety component of the problem
c. Reassure the findings are normal
d. Marital therapy to relieve the frustration
e. Trial of antibiotics
A
Most common cause of deep dyspareunia?
a. ‘oestrogen’
b. retroversion of uterus
c. uterine prolapse
A
The most likely cause of dyspareunia after vaginal delivery is?
a. Uncomfortable stitches
b. Lack of sleep
c. Having intercourse too soon after delivery
d. Atrophic vaginitis
D
With regard to pelvic pain
a. 25% of women will experience it 5 days/month or one full day/month
b. It will have significant impact on work or home life in 2-5% of women
c. It is the reason for 10% of laparoscopies
d. It is the reason for 5% of hysterectomies
e. A full history and examination is rarely helpful in identifying the cause
B
Pelvic pain is the indicated reason for 40% of laparoscopies and 20% of hysterectomies. It will impact on
the work life of 4% of women.
Mild symptomatic endometriosis in young married woman. Rx
a. Danazol 12/12
b. GnRH 3/12
c. Nothing
d. Laparoscopic ablation
D
Endometriosis?
a. Most severe disease have worst symptoms
b. Affected peritoneum almost always seen with naked eye at laparoscopy
c. Most have immunological defect which explains their infertility
d. Medical treatment OK for endometriomas provided they are < 3cm
B
Severe disease does not necessarily correlate with symptoms; ‘Naked eye’ laparoscopy is the gold
standard for diagnosis; there is no immunological defect that describes infertility; medical treatment is
only effective for endometriomas < 1cm
With endometriosis
a. Peritoneal implants are usually visible to the naked eye at laparoscopy
b. Many women with endometriosis have an associated autoimmune condition which may
contribute to the associated infertility
c. Danazol and GnRH derivatives are curative so long as the biggest endometrioma is < 3cm
d. Commonest finding is an ovarian endometrioma
A
