ICSMSU O&G EMQ Practice Flashcards
1.1 The principle supports of the uterus are ❏ A the iliosacral ligaments ❏ B the pyriformis muscle ❏ C the transverse cervical ligaments ❏ D the infundibular ligaments ❏ E the uterosacral ligaments
❏ C the transverse cervical ligaments
❏ E the uterosacral ligaments
1.1 CE
The principle supports of the uterus are the transverse cervical
ligaments (cardinal ligaments), uterosacral ligaments and the
round ligament. The infundibular ligaments attach the ovaries
to the posteo-lateral wall of the uterus. The pyriformis muscle
lines the lateral wall of the pelvis overlying the iliosacral
ligament.
1.2 Which of the following statements are true?
❏ A The ovary is attached to the lateral pelvic side-wall
❏ B The ureter lies beneath the uterine artery
❏ C The mucosa of the fallopian tube is lined by ciliated
cells
❏ D The pouch of Douglas lies between the bladder and the
uterus
❏ E The polar body of the oocyte contains 23
chromosomes
❏ B The ureter lies beneath the uterine artery
❏ C The mucosa of the fallopian tube is lined by ciliated
cells
❏ E The polar body of the oocyte contains 23
chromosomes
1.2 BCE
The ovary is attached to the uterus by the infundibular
ligament, the mesovarium and its blood supply which arises
from the renal arteries. The pouch of Douglas is posterior to the
uterus lying between the rectum and the uterus. Immediately
following the LH surge the oocyte completes the first stage of
meiosis extruding the first polar body which is haploid
(23 chromosomes).
1.3 A 46-year-old woman who has been happily
married for 18 years complains of irregular
vaginal bleeding. Which five of the following
should be performed as first-line investigations?
❏ A Full blood count
❏ B Urea and electrolytes
❏ C Cervical smear
❏ D Cervical swab for chlamydia
❏ E Transvaginal ultrasound scan
❏ F Hysteroscopy and endometrial biopsy
❏ G Endometrial biopsy
❏ H Speculum examination
❏ I Digital vaginal examination
❏ J Group and save
❏ C Cervical smear ❏ E Transvaginal ultrasound scan ❏ F Hysteroscopy and endometrial biopsy ❏ H Speculum examination ❏ I Digital vaginal examination
1.3 CEFHI
In a woman over 40 irregular vaginal bleeding may be due to
any of the following; cervical ectropion, cervical polyp, cervical
cancer, endometrial hyperplasia (cystic or atypical),
endometrial polyp, submucosal fibroid and rarely endometrial
cancer. It is unlikely that she has pelvic inflammatory disease,
and chlamydia rarely causes irregular vaginal bleeding. A
speculum examination is an opportunity to detect cervical
abnormalities and perform a smear. A digital vaginal
examination will detect an enlarged uterus suggestive of
fibroids. Endometrial biopsy alone is indicated in women under
40 because the risk of malignancy is greatly reduced. A
transvaginal ultrasound scan will detect endometrial polyps/
submucosal fibroids and measure the endometrial thickness. A
hysteroscopy and endometrial biopsy is the gold standard for
detecting endometrial abnormalities in women over 40.
1.4 In a sagittal cross section of the pelvis
❏ A the urethra lies anterior to the upper third of the
vagina
❏ B the urethra lies anterior to the lower third of the
vagina
❏ C the bladder when empty lies below and anterior to the
uterine body
❏ D the bladder when empty lies parallel and anterior to
the uterine body
❏ E the rectum lies posterior to the body of the uterus
❏ B the urethra lies anterior to the lower third of the
vagina
❏ C the bladder when empty lies below and anterior to the
uterine body
❏ E the rectum lies posterior to the body of the uterus
1.4 BCE
The urethra is only 3.5 cm long and is anterior to the lower
third of the vagina. The bladder when empty lies below the
uterovesical fold which arises from the junction between the
uterine body and the cervix.
1.5 Which of the following structures lie within the broad ligament? ❏ A The fallopian tube ❏ B The ureter ❏ C The uterine artery ❏ D The ovarian artery ❏ E The superior vesical artery
❏ A The fallopian tube
❏ C The uterine artery
1.5 AC
The broad ligament is made of two layers of peritoneum that
covers the fallopian tube, round ligament, and down the sides
of the uterus to the cervix where anteriorly it merges into the
uterovesical fold and posteriorly the peritoneum of the pouch of
Douglas. The ureter, superior vesical artery and the ovarian
artery are all retroperitoneal. The uterine artery is a branch of
the internal iliac artery and runs between the leaves of the
broad ligament along the lateral wall of the uterus.
1.6 Match the following A–E to five of the statements below. During the menstrual cycle A follicle stimulating hormone B oestradiol C progesterone D testosterone E the first meiotic division ❏ 1 is completed following the LH surge ❏ 2 is produced by the adrenal gland ❏ 3 is completed during the neonatal period ❏ 4 is inhibited by oestradiol ❏ 5 decreases mid-cycle ❏ 6 is a precursor of oestradiol ❏ 7 is inhibited by GnRH ❏ 8 is produced throughout the cycle ❏ 9 is produced in the secretory phase ❏ 10 is secreted by the hypothalamus
During the menstrual cycle A follicle stimulating hormone B oestradiol C progesterone D testosterone E the first meiotic division ❏ 1 is completed following the LH surge ❏ 2 is produced by the adrenal gland ❏ 3 is completed during the neonatal period ❏ 4 is inhibited by oestradiol ❏ 5 decreases mid-cycle ❏ 6 is a precursor of oestradiol ❏ 7 is inhibited by GnRH ❏ 8 is produced throughout the cycle ❏ 9 is produced in the secretory phase ❏ 10 is secreted by the hypothalamus
1.6 A:4 B:8 C:9 D:6 E:1
Testosterone is produced by the thecal cells and converted to
oestradiol by aromatase. Oestradiol is secreted throughout the
menstrual cycle initially by the granulosa cells in the developing
follicle and then by the corpus luteum. Progesterone is
produced by the corpus luteum, changing the endometrium
from proliferative to secretory. The LH surge triggers the final
stage of the first meiotic division whilst fertilisation causes the
second meiotic division with the extrusion of the polar body by
uneven division of the cytoplasm. GnRH is secreted by the
hypothalamus in a pulsatile manner and stimulates the
production and release of LH and FSH in the anterior pituitary
gland. Androgen precursors are secreted by the adrenal but
oestradiol is only produced in the ovary.
1.7 Complications of laparoscopy include perforation of the ❏ A gall bladder ❏ B urinary bladder ❏ C uterus ❏ D inferior vesical artery ❏ E inferior epigastric artery
❏ B urinary bladder
❏ C uterus
❏ E inferior epigastric artery
1.7 BCE
Trocars placed in the iliac fossae can perforate the inferior
epigastric artery while one placed centrally can perforate the
bladder. The uterus can be perforated by a sound placed in the
uterus to move it around.
1.8 In the follicular phase of the menstrual cycle
❏ A the granulosa cells produce androstenedione and
testosterone
❏ B the endometrial glands become straight
❏ C oestradiol inhibits the production of LH
❏ D the thecal cells produce oestradiol and secrete
follicular fluid
❏ E the nucleus of the oocyte contains 23 chromosomes
❏ B the endometrial glands become straight
❏ C oestradiol inhibits the production of LH
1.8 BC
The granulosa cells produce oestradiol while the thecal cells
produce the androgens androstenedione and testosterone.
Prior to the LH surge the oocyte contains 46 chromosomes. The
LH surge occurs at the end of the follicular phase.
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Paper 1 – Answers and Teaching Notes
1.9 In embryo development
❏ A beta human chorionic gonadotrophin (βhCG) is produced
by the fallopian tube from the moment of fertilisation
❏ B the blastocyst divides into two halves, one forming the
embryo, the other the placenta
❏ C the villi of the developing embryo invade the maternal
capillaries
❏ D the fetal heart starts beating at around five weeks
from date of last menstrual period
❏ E haemoglobin F has a lesser affinity for oxygen than
haemoglobin A
❏ B the blastocyst divides into two halves, one forming the
embryo, the other the placenta
❏ D the fetal heart starts beating at around five weeks
from date of last menstrual period
1.9 BD
βhCG is produced by the developing trophoblast of the embryo.
The developing trophoblastic villi of the placenta invade into the
maternal capillary bed so that the endotheliums of the maternal
and fetal capillaries are in close contact. The integrity of the
maternal capillaries remains intact and there is no direct
circulation between the maternal and fetal circulations at any
time. Haemoglobin F differs from HbA by 25% of its amino
acids. This allows the oxygen dissociation curve of HbF to move
to the left of HbA so that for any given p(O2) concentration HbF
has a greater affinity for oxygen than HbA.
1.10 After birth which of the following changes occur
in the fetus?
❏ A The foramen ovale closes allowing the entire blood
volume to circulate into the pulmonary artery
❏ B Lung fluid is forced out of the fetal alveoli with the first
few breaths
❏ C The ductus arteriosus opens
❏ D Haemoglobin F is replaced by haemoglobin A
❏ E The umbilical vein and artery remain open for several
weeks
❏ A The foramen ovale closes allowing the entire blood
volume to circulate into the pulmonary artery
❏ B Lung fluid is forced out of the fetal alveoli with the first
few breaths
❏ D Haemoglobin F is replaced by haemoglobin A
1.10 ABD
The foramen ovale, the ductus arteriosus and the umbilical
veins and arteries close within a few hours of birth. The
breakdown of fetal blood cells in the first few days of life allows
HbF to be replaced by HbA with its lower affinity for oxygen.
This may lead to physiological jaundice in the newborn.
1.11 Mark as true the five best matched statements
about βhCG:
❏ A βhCG begins to rise two weeks after fertilisation
❏ B βhCG is measured using a monoclonal antibody
radioimmunoassay
❏ C It is a hormone secreted by the trophoblastic cells of
the developing placenta
❏ D The β-subunit is the same as TSH and FSH
❏ E A low level of βhCG is associated with an increased
risk of a baby with Down’s syndrome
❏ F The half-life of βhCG in plasma is 96 hours
❏ G A high level of βhCG is associated with a hydatidiform
mole
❏ H Serial βhCG measurements are useful in the diagnosis
of an ectopic pregnancy
❏ I βhCG is a polypeptide protein produced by the
hypothalamus
❏ J A high level of βhCG is associated with a multiple
pregnancy
❏ A βhCG begins to rise two weeks after fertilisation
❏ C It is a hormone secreted by the trophoblastic cells of
the developing placenta
❏ G A high level of βhCG is associated with a hydatidiform
mole
❏ H Serial βhCG measurements are useful in the diagnosis
of an ectopic pregnancy
❏ J A high level of βhCG is associated with a multiple
pregnancy
1.11 ACGHJ
βhCG is a polypeptide protein produced by the trophoblastic
cells of the developing placenta. It has a half-life in plasma of
48 hours. It shares its β-subunit with luteinising hormone. It is
measured using a monoclonal ELISA test. βhCG levels are raised
in multiple pregnancies, Down’s syndrome, hydatidiform mole,
choriocarcinoma, some gonadoblastomas and dysgerminomas.
In ectopic pregnancy βhCG increases at a slower rate than an
ongoing intrauterine pregnancy (doubles every 48 hours).
1.12 Which of the following statements are true about
luteinising hormone (LH)/follicle stimulating
hormone (FSH)?
❏ A They are glycoproteins
❏ B They are secreted continuously by the pituitary gland
❏ C LH stimulates the formation of the corpus luteum
❏ D LH and FSH increases in the middle of the cycle
❏ E The LH surge occurs in the middle of a 28 day cycle
and lasts for three days
❏ A They are glycoproteins
❏ C LH stimulates the formation of the corpus luteum
❏ D LH and FSH increases in the middle of the cycle
❏ E The LH surge occurs in the middle of a 28 day cycle
and lasts for three days
1.12 ACDE
LH and FSH are two glycoproteins secreted by the pituitary in
response to a GnRH pulse and thus have a pulsatile pattern of
secretion themselves. In the middle of a 28 day cycle/at
ovulation there is a sudden and large increase in the secretion
of LH and FSH, the LH surge lasts for three days. LH luteinises
the granulosa cells which start to produce progesterone in the
corpus luteum.
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1.13 Mark as true the five best matched statements
about the menopause:
❏ A The current average age of menopause in the US is
51 years
❏ B LH levels rise before FSH levels
❏ C The ovaries become more resistant to the action of FSH
❏ D FSH levels rise before LH levels
❏ E Menopausal women are prone to vertebral crush
fractures
❏ F The risk of myocardial infarction is reduced in
menopausal women
❏ G Lack of oestrogen leads to osteopenia
❏ H Variation in cycle lengths is more common around the
time of the menopause
❏ I High FSH levels cause hot flushes
❏ J Menopausal women rarely complain of dyspareunia
❏ A The current average age of menopause in the US is
51 years
❏ C The ovaries become more resistant to the action of FSH
❏ D FSH levels rise before LH levels
❏ E Menopausal women are prone to vertebral crush
fractures
❏ H Variation in cycle lengths is more common around the
time of the menopause
1.13 ACDEH
The current average age of the menopause is 51 years. The
ovaries gradually become more resistant to the action of FSH
so oestrogen concentrations remain low because few or no
follicles develop. This leads, by negative feedback, to an
increase in FSH concentrations. LH concentrations rise later
than FSH concentrations. Low oestrogen levels cause hot
flushes (not FSH), and osteoporosis with loss of trabecular
bone leading to vertebral crush fractures and fractures of the
neck of femur. In addition atrophic vaginitis is common, often
causing dyspareunia because of lack of vaginal secretions and
poor elasticity of the vagina.
1.14 A 26-year-old primigravid woman at ten weeks
gestation visits her midwife for a routine booking
appointment. She has sickle cell anaemia. Her
partner’s sickle cell status is HbAS. What are the
chances of her baby having sickle cell disease?
❏ A 1 in 8
❏ B 1 in 4
❏ C 1 in 5
❏ D 1 in 2
❏ E 1 in 3
❏ D 1 in 2
1.14 D
The baby can only inherit HbS from its mother but can inherit
either HbA or HbS from its father. This gives a one in two
chance of the baby having either sickle cell trait or sickle cell
disease.
1.15 Which one of the following statements about
amniotic fluid is correct?
❏ A The volume of amniotic fluid has no prognostic value
in pregnancy
❏ B An increased amniotic fluid volume may be associated
with fetal chromosomal abnormalities
❏ C A decreased amniotic fluid volume may be associated
with fetal chromosomal abnormalities
❏ D Amniotic fluid is derived solely from the amnion at 36
weeks
❏ E Amniotic fluid contains bilirubin in healthy pregnancies
❏ C A decreased amniotic fluid volume may be associated
with fetal chromosomal abnormalities
1.15 C
Amniotic fluid volume is often decreased in fetuses that are
hypoxic. An increased amniotic fluid volume is associated with
some congenital abnormalities while a decreased volume is
found in babies with trisomy 13, 16 and 18 who often have
renal agenesis. Bilirubin is only found in babies with hydropic
disease of the newborn, most commonly due to rhesus
isoimmunisation.
