A 47 year old woman with detrusor over-activity has been successfully treated with botulinum

toxin A. Five months later, her symptoms recur

Question 1

Options for Questions 1-1

A

Refer to the urogynaecology multi-disciplinary

team

C Offer treatment with anti-cholinergic drugs

Offer repeat treatment with botulinum toxin A

Offer posterior tibial nerve stimulation

E Offer treatment with botulinum toxin B

A(Correct answ er: B)

Explanation
Repeat treatment
If botulinum toxin A treatment is effective, offer follow-up at 6 months or sooner if symptoms return for
repeat treatment without an MDT referral
Tell women how to self-refer for prompt specialist review if symptoms return.
Botulinum toxin B is not recommended for the treatment of women with idiopathic OAB

Question 2

A 67 year old woman is being treated with mirabegron for urinary incontinence. She has a history
of cardiac disease treated with digoxin.

Options for Questions 2-2

A Increase the dose of digoxin

Reduce the dose of digoxin

C Increase the dose of mirabegron

Reduce the dose of mirabegron

E Add aspirin to digoxin

A(Correct answ er: B)

Explanation
Mirabegron - Drug interactions
Clarithromycin
Avoid or reduce dose of mirabegron in hepatic or renal impairment when given with clarithromycin
Digoxin
Mirabegron increases plasma concentration of digoxin reduce initial dose of digoxin
Itraconazole
Avoid or reduce dose of mirabegron in hepatic or renal impairment when given with itraconazole
Metoprolol
Mirabegron increases plasma concentration of metoprolol
Ritonavir
Avoid or reduce dose of mirabegron in hepatic or renal impairment when given with ritonavir

Question 3

The incidence of hyperemesis gravidarum is

Options for Questions 3-3

A 0.1 0.2 per 1000 pregnancies

0.5 1.5 per 1000 pregnancies

C 4 10 per 1000 pregnancies

12 14 per 1000 pregnancies

E 20 25 per 1000 pregnancies

A(Correct answ er: C)

Explanation

HYPEREMESIS GRAVIDARUM
Vomiting severe enough to require hospital admission - associated with dehydration + weight loss of at least 3kg.
Affects 3-10 women /1000 pregnancies
Presents in first trimester and is unusual after 16 weeks gestation.
Peak incidence 8-12 weeks
Aetiology not fully understood but related to HCG and TSH levels +/- psychological factors. There is, however, no
direct relationship between the severity of the disorder and HCG or TSH levels
An association exists with hyperthyroidism, pyridoxine deficiency, and psychological factors
50% recurrence rate
Diagnosis of exclusion - UTI / Gastroenteritis / pancreatitis / peptic ulceration, hepatitis, diabetic ketoacidosis, acute
appendicitis should be considered
Associated with metabolic alkalosis - hypochloraemic alkalosis with hypokalaemia and potassium loss in urine
Urine is acidic despite systemic alkalosis - when alkalosis is associated with volume depletion, bicarbonate is not
excreted
Excretion of bicarbonate only occurs with restoration of extracellular fluid volume

Question 4

The biochemistry of hyperemesis gravidarum is characterised by

Options for Questions 4-4

A Metabolic acidosis and hypochloraemia

Metabolic alkalosis and hyperchloraemia

C Hypokalaemia and hyperchloraemia

Hyperkalaemia and hypochloraemia

E Metabolic alkalosis and hypochloraemia

A(Correct answ er: E)

Explanation

HYPEREMESIS GRAVIDARUM
Vomiting severe enough to require hospital admission - associated with dehydration + weight loss of at least 3kg.
Affects 3-10 women /1000 pregnancies
Presents in first trimester and is unusual after 16 weeks gestation.
Peak incidence 8-12 weeks
Aetiology not fully understood but related to HCG and TSH levels +/- psychological factors. There is, however, no
direct relationship between the severity of the disorder and HCG or TSH levels
An association exists with hyperthyroidism, pyridoxine deficiency, and psychological factors
50% recurrence rate
Diagnosis of exclusion - UTI / Gastroenteritis / pancreatitis / peptic ulceration, hepatitis, diabetic ketoacidosis, acute
appendicitis should be considered
Associated with metabolic alkalosis - hypochloraemic alkalosis with hypokalaemia and potassium loss in urine
Urine is acidic despite systemic alkalosis - when alkalosis is associated with volume depletion, bicarbonate is not
excreted
Excretion of bicarbonate only occurs with restoration of extracellular fluid volume

Question 5

A 17 year old woman has surgical evacuation of a molar pregnancy at 8 weeks gestation.
Karyotype is reported as 46XX. The risk of her needing chemotherapy is

Options for Questions 5-5

A 1-2%

5-7%

C 15-18%

25-30%

E 40-50%

A(Correct answ er: C)

Explanation

Risk factors for malignant change / need for chemotherapy

Maternal age: 9 fold increase in risk in >40 years compared to 20-24 age group
Initial method of evacuation: lowest risk after vacuum aspiration
ABO blood group: highest risk in woman with blood group A and partner with blood group O; lowest risk in woman
with blood group A and partner with blood group A
Complete or partial mole: malignant potential higher with complete mole: about 16% require chemotherapy compared
to 0.5%% after partial mole
Post-evacuation contraception: COCP may be used even before HCG levels have returned to normal

Question 6

Factor V Leiden mutation is associated with

Options for Questions 6-6

A Recurrent first trimester miscarriage

Pre-eclampsia

C Placental abruption

Fetal growth restriction

E Post-partum haemorrhage
A(Correct answ er: A)

Explanation

Inherited thrombophilias
Include protein C / S and antithrombin III deficiency, activated protein C resistance (most commonly Factor V Leiden
mutation), hyperhomocystinaemia, prothrombin gene and Methylenetetrahydrofolate mutation.
Factor V Leiden mutation is associated with recurrent first-trimester miscarriage, recurrent fetal loss after 22 weeks
and non-recurrent fetal loss after 19 weeks
Activated protein C resistance is associated with recurrent first-trimester miscarriage.
Prothrombin gene mutation is associated with recurrent first-trimester miscarriage, recurrent fetal loss before 25
weeks and late non-recurrent fetal loss.
Protein S deficiency is associated with recurrent fetal loss and non-recurrent fetal loss after 22 weeks.
Methylenetetrahydrofolate mutation and protein C and antithrombin deficiencies are not associated with fetal loss.
Protein C and antithrombin III deficiencies are rare.

Question 7

A 31 year old woman with an ectopic pregnancy has been treated with single dose
methotrexate. The dose of methotrexate should be calculated based on

Options for Questions 7-7

A The womans GFR

The womans body surface area

C The womans BMI

The womans weight

E The gestation age

A(Correct answ er: B)

Explanation
Among women trying to become pregnant, intra-uterine pregnancy rate = 54% and recurrent ectopic rates = 8-10% comparable to those following laparoscopic salpingostomy??
Intra-muscular methotrexate - dose calculated pre m2 body surface area (50mg/square m)??

Question 8

A 23 year old woman with epilepsy has been referred for antenatal care. She enquires about
vitamin K supplementation. She needs vitamin K

Options for Questions 8-8

A

From 34 weeks if she is taking any anti-epileptic

B
drugs

From 34 weeks regardless of whether she is

taking any anti-epileptic drugs

From 34 weeks if she is taking enzyme-inducing

D
anti-epileptic drugs

From 34 weeks if she is taking more than one

anti-epileptic drug

At the time of delivery if she is taking enzymeinducing anti-epileptic drugs

A(Correct answ er: C)

Explanation
Maternal vitamin K supplementation from 34-36 weeks in women taking enzyme-inducing AEDs to reduce the risk of
maternal and neonatal bleeding. May be oral or im

Question 9

With respect to Von Willebrands disease

Options for Questions 9-9

Type I Von Willebrands disease is characterized

B
by very low levels of Von Willebrands factor

Type II Von Willebrands disease is characterized

by a qualitative deficiency of Von Willebrabds
factor

Type II and Type III Von Willebrands disease are

D
autosomal dominant disorders

Levels of Von Willebrands factor decrease in

pregnancy

Von Willebrands disease can be diagnosed from

the clotting time
A(Correct answ er: B)

Explanation
VON WILLEBRAND'S DISEASE ???

Inherited deficiency of von Willebrand factor (vWF).??

Type 1 - quantitative deficiency - autosomal dominant, mild bleeding disorder - improves during pregnancy??

Type 2 - qualitative deficiency - autosomal dominant, mild bleeding disorder - usually improves during
pregnancy??

Type 3 - very low / absent vWF and low VIII - autosomal recessive, severe bleeding disorder - no improvement
during pregnancy??

Diagnosed by reduced plasma ristocetin cofactor +/- reduced vWF?

Pregnancy, exercise, stress, inflammation and recent surgery increase VIII and vWF levels

IX levels do not rise significantly in pregnancy

Question 10

A 33 year old woman has been referred for colposcopy because of high grade dyskaryosis
(moderate).

Options for Questions 10-10

A

Either an excision biopsy or a colposcopically

directed punch biopsy should be undertaken

C Biopsy is unnecessary if colposcopy shows CIN 1 D

A colposcopically directed punch biopsy should
E only be undertaken if local destructive therapy is
being offered

Biopsy is unnecessary if colposcopy is normal

A punch biopsy should not be undertaken in such
women