SELF-ASSESSMENT

Self assessment questions

Questions EMQ 5
Please match one of the following structures to each of the
SBA 1
four statements below.
Concerning termination of pregnancy in the UK, which of the
A. Peritoneum
following is true:
B. Bowel
A. In the UK, women can now self-administer at home all the
C. Ureter
drugs for medical termination of pregnancy.
D. Broad ligament
B. In 2018 50% of all terminations of pregnancy in Scotland
E. Uterine lower segment
involved self-administration of misoprostol at home.
F. Rectus sheath
C. In 2018, 71% of terminations in England and wales were
G. Bladder
medically induced.
H. Subcutaneous fat
D. In 2018, 91% of terminations in England and Wales were
1. This is the main organ at risk of injury during caesarean
funded by the NHS.
sections
2. When injury is to this organ is suspected or recognized
SBA 2
before delivery of the fetus, the area should be marked
Regarding termination of pregnancy procedures, which of the
with a stitch and covered with a moist pack.
following is true?
3. Current evidence suggests that closure of this increases
A. Uterine perforation is associated with 1 in 100 surgical
operative time by 6 minutes
terminations of pregnancy, and approximately 1 in 10,000
4. Closure of this aims to prevent the formation of seromas or
require laparotomy for repair.
haematomas
B. Approximately 90% of terminations are without
complication. SBA 6
C. If a woman has a minor perforation without bleeding or Which of the following is not a risk factor for haemorrhage at
any other injury, there is no requirement to inform the caesarean section?
patient. A. Prolonged labour
D. A woman’s risk of death during a safe termination is twice B. Chorioamnionitis
that during pregnancy and childbirth. C. General anesthesia
D. Previous caesarean section
SBA 3 E. Obesity
In the UK and many European countries, cervical screening
will soon move to which following combination? SBA 7
A. Cytology primary screening; HPV DNA for triage of In general, in which of the following scenarios is an insulin
cytology-positive women pump in pregnancy not indicated?
B. HPV DNA primary screening; cytology for triage of HPV- A. Insulin-treated diabetic women who are struggling to meet
positive women their HbA1c targets despite carbohydrate counting
C. Cytology primary screening: HPV mRNA for triage of B. Insulin-treated diabetic women who are struggling to meet
cytology-positive women their HbA1c targets despite appropriate structured educa-
D. None of the above tion (such as Dose Adjustment for Normal Eating, DAFNE)
C. Any insulin-dependent gestational diabetic women with
SBA 4 uncontrolled hyperglycaemia
Which of the following groups include all HPV-associated D. Insulin-treated diabetic women whose attempts to achieve
cancers? their HBA1c targets results in unacceptable levels of
A. Cervical, vaginal, vulval, endometrial, penile hypoglycaemia.
B. Cervical, vaginal, endometrial, penile, oral EMQ 8
C. Cervical, vaginal, anal, penile, oral Please match each of the four statements below to one of the
D. Cervical, vaginal
following insulin pump terms.
A. Blood glucose target
B. Basal rate
Norman Shreeve BSc BMBS is a Specialty Registrar at Adden- C. Insulin carbohydrate ratio
brooke’s Hospital and Wellcome Trust Clinical PhD Fellow at the D. Insulin sensitivity factor
Centre for Trophoblast Research, and Department of Obstetrics E. Total daily dose
and Gynaecology, University of Cambridge, Cambridge, UK. F. Temporary basal rate
Conflicts of interest: none declared. G. Insulin on-board

OBSTETRICS, GYNAECOLOGY AND REPRODUCTIVE MEDICINE 30:4 130 Ó 2020 Published by Elsevier Ltd.
 SELF-ASSESSMENT

H. Bolus calculator/bolus wizard This figure is higher than 2017 (66%), and almost
1. The amount 1 unit of insulin reduces blood glucose by in double the proportion in 2008 (37%). In 2018 in Scotland
mmol/L. 86.1% of terminations were medically induced. It remains
2. This is a mathematical calculation of the amount of active illegal for women in the UK to self-administer oral mife-
insulin in a patient’s system pristone; however, mifepristone must be taken in hospital.
3. The amount of insulin given per gram of carbohydrate In 2018 98% of abortions in England and wales were
ingested funded by the NHS.
4. The rate of insulin infusion being delivered in units per
SBA 2
hour
A
EMQ 9 98e99% of all terminations are complication free. It is
In each of the following scenarios, please select the single important that all women who have a perforation of the uterus
most appropriate treatment or investigation from the list during a surgical termination of pregnancy should be fully
below. informed. A woman’s risk of death during safe termination of
A. Endometrial biopsy pregnancy is 10 times less than that during pregnancy and
B. Mirena coil childbirth.
C. Transvaginal ultrasound
SBA 3
D. Endometrial ablation
B
E. Myomectomy
HPV primary screening will be introduced, with cytology
F. MRI
for triage of HPV positive women. Only HPV positive women
G. Uterine artery embolization
with borderline or worse cytology will be referred to colpos-
H. Ulipristal
copy, the remainder will be discharged to routine recall.
I. Hysterectomy
J. Transcervical resection SBA 4
1. A 52-year-old patient with a BMI of 44, has pressure C
symptoms due to a 9-cm posterior subserosal fibroid. She Although adenocarcinoma arising in the endocervix is HPV
has had two midline laparotomies for Crohn’s disease of associated, endometrial cancer types are not caused by HPV
which one was complicated by peritonitis. The radiologist disease and in most cases the strongest epidemiological risk
has declined embolization. factor is unopposed oestrogen such as in obesity and high
2. A 30-year-old needs to have IVF as her partner has poor parity.
sperm quality. At the initial consultation, she mentions EMQ 5
that her cycle is regular and she bleeds for 7 days with her 1. G
periods being painful. She can fill a maxi pad in 1 h during If the bladder is inadvertently opened, the damage should
the first 2 days. be assessed by noting the location and size of the defect and its
3. A 43-year-old patient with a completed family has an 18- relation to the ureteric orifices. A urologist should be con-
weeks’ size multifibroid uterus. Despite medical treat- tacted in the case of extensive damage.
ment her menorrhagia is causing anaemia and she has 2. B
problems passing urine. It should be repaired in conjunction with a general sur-
4. A 54-year-old patient presents with an episode of vaginal geon, after the uterine incision is closed. Small bowel damage
bleeding. Her last real period was 18 months ago. An ul- is repaired using a two-layer procedure and large bowel in the
trasound shows a 3-cm intramural fibroid and an endo- same way, but sometimes requiring a temporary defunction-
metrial thickness of 6 mm. What will you do next? ing colostomy. Postoperative broad-spectrum antibiotics are
SBA 10 essential.
A 43-year-old Afro-American nun is diagnosed with anaemia. 3. A
On further questioning she informs you her periods are heavy. Current advice from NICE is that non-closure of the peri-
On examination you feel an enlarged uterus. What will be toneum is preferable to closure as it reduces operating time, is
your working diagnosis? associated with lower postoperative analgesia requirement
A. Endometrial polyp and therefore improves maternal satisfaction
B. Pregnancy 4. H
C. Uterine fibroids The aim is to close any potential dead space that may allow
D. Ovarian cyst formation of seromas or haematomas, which can lead to
F. Uterine sacroma infection and therefore delayed healing.
SBA 6
Answers D
Previous PPH is a risk factor. The commonest cause of
SBA 1 haemorrhage is uterine atony.
C

OBSTETRICS, GYNAECOLOGY AND REPRODUCTIVE MEDICINE 30:4 131 Ó 2020 Published by Elsevier Ltd.
 SELF-ASSESSMENT
SBA 7
C for surgery. This prescription is done in secondary care, and
Generally, insulin pumps are approved for people with
diabetes who are struggling to meet HbA1c targets with
multiple-daily injections despite appropriate structured edu-
cation (such as Dose Adjustment for Normal Eating, DAFNE)
and carbohydrate counting or in whom attempts to achieve
such a target results in unacceptable levels of hypoglycaemia.
EMQ 8
1. D
This is different on a patient-to-patient and occasionally on
a meal-to-meal basis. It is used to calculate correction doses to
achieve the pre-specified blood glucose target. A starting factor
of 1 unit reducing blood glucose by 3 mmol/L is often used.
2. G
The pump will take this into account when calculating and
delivering a bolus of insulin.
3. C
This is different on a patient-to-patient and meal-to-meal
basis. A starting ratio of 1 unit for 10 g carbohydrate is often
used.
4. B
This can be programmed to change up to half hourly to
account for individual requirements.
EMQ 9
1. H
OBSTETRICS, GYNAECOLOGY AND REPRODUCTIVE MEDICINE 30:4
Ulipristal can be given in a patient with contra-indication
liver function tests need to be performed every 3 months.
2. C
Even though there might be male subfertility, implantation
and success rate of IVF are related to the uterine cavity. In this
case, the patient has a submucosal fibroid, she needs to have
counselling about removing this to improve fertility treatment
outcome and the risks related to this treatment so that the
couple can make an informed decision.
3. I
In a very large uterus which is therapy resistant the only
definitive way of treating the fibroids would be a hysterec-
tomy. The surgeon might consider pre-treatment to stop any
menstrual bleeding and improve the pre-operative
haemoglobin.
4. A
This patient is post-menopausal. The fibroid is an inci-
dental finding on scan. Endometrial atypia needs to be
excluded in post-menopausal bleeding.
SBA 10
C
Age, ethnicity and nulliparity are risk factors for having
fibroids. Fibroids can cause heavy and prolonged menstrual
bleeding, leading to anaemia. The risk of a malignancy is
present but low.
132 Ó 2020 Published by Elsevier Ltd.