MRCOG Part 2 - Free Grand Mock - Paper 2 - EMQ

1. A 27 -year-old pregnant woman is seen for her initial pregnancy visit. She is estimated to be at 22 weeks gestation. She reports being in a monogamous relationship with her current partner of 3 months. She has had 4 partners in the year prior to becoming pregnant. She was last tested for sexually transmitted diseases (STDs) 8 months ago, including serologic testing for syphilis, and all tests were negative. Her physical examination is unremarkable. Routine laboratory screening tests are performed, including a serologic test for syphilis. They show a positive treponemal enzyme immunoassay (EIA) and a positive Rapid Plasma Reagin (RPR) assay (titer 1:16). The HIV antigen-antibody test is negative. She is brought back into clinic for treatment and she tells you she gets hives when exposed to penicillin. She has no neurological or eye signs or symptoms.

A.Treat with doxycycline 100mg BD for 14 days
B.Treat with cefixime 200mg BD for 14 days
C.Treat with azithromycin 1gm stat
D.Promptly refer her for desensitization and treatment of syphilis with penicillin
E.Doxy 100mg BD for 7 days
F.Metronidazole gel 0.75%, one full applicator (5 grams) intravaginally, once a day for 5 days
G.BV not treated during pregnancy
H.Fluconazole 150mg oral single dose
I.Nystatin cream 100,000 units intravaginally twice daily for 7 days
J.Clotrimazole 10% cream 5 grams intravaginally daily for 7 days
K.No antifungal is considered safe in pregnancy
L.Amoxicillin 500mg twice daily for 7 days
M.Doxy 100mg BD for 7 days
N.Dicloxacillin 250mg QID for 10 days
O.Azithromycin 1 gram orally in a single dose followed by 500mg OD for next 2 days.
P.Erythromycin 500 mg orally four times daily for 21 days

Which of the above is the best treatment option for the scenarios given below?

Each option may be used once, more than once, or not at all. What is your next best course of management?

2. A 38-year-old female presents with a 10-day history of malodorous vaginal discharge. She denies fevers, chills, pruritus, dysuria, pain during sex, or pelvic pain. She is 24 weeks pregnant and has had an uncomplicated pregnancy to date. She engages in vaginal sexual intercourse with one male partner (her husband), with whom she has been monogamous for 5 years. She is diagnosed with bacterial vaginosis.

3. A 29-year-old female presents with a 5-day history of vaginal itching, redness, and a new thick white vaginal discharge. She denies fevers, chills, or pelvic pain. The patient is 25 weeks pregnant with her first child and has had an uncomplicated pregnancy to date. She is sexually active and monogamous with her husband of 5 years. A wet preparation of the vaginal discharge reveals yeast and pseudohyphae.

4. A 26-year-old woman presents to the health department after having unprotected sex 6 weeks prior and requests a pregnancy test, which is positive. Based on her last menstrual period, she is 18 weeks into her pregnancy. She consents to STD screening at the same time. Two days later, the health department notifies her that she has tested positive for chlamydia.

5. A 39-year-old woman pregnant with her first child presents to clinic for evaluation of dysuria and painful left-sided inguinal adenopathy. She is a recent immigrant from Southern India. She is 21 weeks pregnant and has been healthy and well up to this point. Her symptoms have been present for the past 7 days with progressive worsening of the adenopathy. Nucleic acid amplification testing (NAAT) on an endocervical swab is positive for Chlamydia trachomatis; tests for Neisseria gonorrhoeae, herpes simplex virus, and syphilis are all negative. The patient is diagnosed with probable lymphogranuloma venereum (LGV).

6.A 28 years old couple visits subfertility clinic with failure to concieve since 2 years .The BMI of woman is 32. She does not get menses with progesterone withdrawal . You advise the couple baseline investigations. She visit you the next day with following TVS report .

A.FSH
B.LH
C.Polycystic ovaries
D.Hysterosalpingography
E.hysterosalpingo-contrast-ultrasonography
F.Hysteroscopy
G.Dermoid Ovarian cyst
H.OHSS
I.Gonadotropin
J.Tamoxifen
K.GnRH agonist
L.Plan for IUI
M.DHEA
N.Free Testosterone
O.Combination with metformin
P.Combination with GnRH agonist
Q.Laparoscopy and dye test
R.Clomiphene Citrate

What is your diagnosis?

7.What investigation would you advise next to confirm your diagnosis?

8.Since she is having anovulatory cycles, you decide to induce ovulation. Which of the following is the drug of first choice?

9.She has failed to ovulate even after the medication . What will you do next ?

10.She had ovulation but she failed to concieve even after 6 months . You decide to check her tubal patency . She also gives history of dyspareunia and chronic pelvic pain . Which of the following is most suitable test to look for tubal patency ?

11.A 28 years old woman has been referred to up you by her GP , as he wants you to explain her an USG report which he advised as she was having complaint for dysmenorrhea, dyspareunia and cyclical painful defaecation . The USG image is as shown below .

A.Endometrioma
B.Good quality cleavage stage
C.Good quality blastocyst
D.Poor quality cleavage stage
E.Molar pregnancy
F.8 weeks
G.12 weeks
H.225 IU/day
I.Pelvic hematoma
J.Co2 laser vaporisation
K.10 weeks
L.Cystectomy
M.Drainage and coagulation
N.AFC = 10
O.FSH = 2 IU/l
P.AMH = 1.73 pmol/l
Q.300 IU/day
R.450 IU/day
S.600 IU/ day

What is your diagnosis ?

12.She is also keen for pregnancy . After treatment, she has been decided for IVF . Which of the given options indicates low response to stimulation ?

13.What is the maximum dose of gonadotropin that can be given to her ?

14.Mrs Abiola Owaluki, has recently moved from Nigeria to the UK. She is booking in her first pregnancy at 10 weeks. She has no medical or surgical history of relevance. Her BMI is 32. What does of folic acid is advised for her?

A.400IU
B.400mg
C.400μg
D.5mg
E.800IU
F.1000IU
G.10mg
H.10µg
I.50mg
J.100mg
K.50mg/m2
L.1mg
M.5µg

15. Mrs Patricia has conceived 18 months after a bariatric surgery. Her current BMI is 29. What is the dose of Vit D recommended for her?

16. Mrs Valeria, is planning her second pregnancy after having an IUD 1 year ago due to a condition she says where the “part of baby’s brain was missing” which of these doses of folic acid would you recommend for her?

17. Mrs Paula G2P1, 40-year-old has come with an unplanned pregnancy with her 11-year-old. After lengthy discussion she has decided to continue the pregnancy. What does of Vitamin D would you recommend for her?

18. Mrs. Deepthi , A 29-year-old G2P1 with a booking BMI of 35 had a placental abruption and an emergency caesarean section at 37 weeks of gestation in her previous pregnancy. She is currently on low dose aspirin 75 mg in the current pregnancy. The previous fetal weight at birth was 1718g at 37 weeks. You are about to see her following a 20 week anomaly scan in an antenatal clinic. Where she should be taking her antenatal care ?

A.Consultant-led care and measure symphysis-fundal height (SFH) in all antenatal visits
B.Administer corticosteroids
C.Suggest a category 1 Caesarean section
D.Consultant-led care in a high risk pregnancy clinic and serial growth scans
E.Administer magnesium sulphate for fetal neuroprotection
F.Referral for ultrasound scan after a single SFH measurement below the 10th centile or serial measurements that would suggest a slow or static growth
G.Regular visits to the community midwife and growth scans at 28 and 34 weeks of gestation.
H.The use of a population based chart rather than a customised growth chart
I.Shared care with regular visits to the community midwife and review in hospital if required
J.Administer steroids and inform the neonatal unit
K.Suggest a fetal blood sampling
L.Perform ARM followed by an instrumental delivery in theatre

Various options show management options of small for gestational age .

The following scenarios show women having babies with IUGR . Choose the most appropriate option for each of them .each option can be used once, more a than once or none at all.

19.Mrs. Deeksha , 39-year-old primiparous woman is currently 35+3 weeks pregnant. She is a smoker and on methyldopa for gestational hypertension. Her urinalysis is negative for protein. Ultrasound examination showed a small-for-gestational-age fetus less than 10th centile. Doppler image is enclosed .

You discuss with a consultant and plan to deliver the baby.

What’s the next step ?

20. Ms. Sweetie , A 25-year-old Asian primagravida presents for her booking appointment. Her sister has recently had a baby that was small and was admitted into special care for 4 weeks. She is worried about her baby being small too and requests serial growth scans from 28 weeks of gestation.

21.Mrs, Dolly , 31-year-old woman presents at 34 weeks of gestation in preterm labour. On examination she is found to be 10 cm dilated with the presenting part at –2 above the ischial spines. She had an ultrasound scan 2 days ago, which revealed a small for dates baby with an estimated fetal weight of 1.2 kg. CTG is enclosed

22.Mrs. Geeta , 32 year old primigravida with twin gestation now 30 weeks pregnant .she is here todiscuss her labour plan. She is asking what’s the ideal getstaion for her to deliver ?photographic image of her dating scan is enclosed

A.30+0

B.32+6

C.32+0

D.32-34

E.34-36

F.34+0

G.36+0

H.37+0

I.38+0

The options above show various gestational age. Following women show various scenarios of twin gestation .for each of them choose the appaoritae gestation age .

23. Mrs, savitha , 30 year old is on a booking visit with the image enclosed . She is here to discuss her labour plan. She is asking what’s the ideal gestation for her to deliver ?A photographic image of her dating scan is enclosed .

24.A 26-year-old woman attends the emergency department with a history of lower abdominal pain and feeling unwell, 5 days after an emergency caesarean section for failure to progress in the second stage after a failed instrumental delivery. Estimated blood loss at delivery was 1500 ml. She recovered well postoperatively and was discharged on day 3. Her pulse was 112, BP 100/60 mmHg, temperature 38.6°C, respiratory rate 20 and oxygen saturation 98%. On examination, she was tender in the lower abdomen with guarding and bowel sounds were present. Her WBC was 16K and CRP 250. Though there is some clinical improvement after admission with intravenous antibiotics, she still has swinging temperatures.

A.Atelectasis
B.Pulmonary embolism
C.Paralytic ileus
D.Bowel perforation
E.Uterine dehiscence
F.Endometritis
G.Infected pelvic collection
H.Uterine perforation
I.Small bowel obstruction
J.Ureteric injury

Instructions

For each clinical scenario below, choose the single most likely surgical complication from the above list of options. Each may be used once, more than once or not at all.

25.A 34-year-old woman with a BMI of 40 attends the emergency department with a history of sudden onset of left abdominal pain and fever with rigors, ten days postoperatively after an emergency caesarean section for failure to progress in the second stage after failed instrumental delivery. At delivery, there was an extension of the left uterine angle with massive haemorrhage, which was controlled by placing multiple haemostatic sutures and securing uterine angles. Her pulse is 116, BP 110/80 mmHg and temperature 38°C. On examination, there is tenderness in the left lower abdomen and left flank. Her WBC is 15 and CRP is 110.

26.A 28-year-old woman attends the emergency department with severe lower abdominal pain and feeling unwell, on day 2 after a diagnostic laparoscopy for chronic pelvic pain and subfertility. Her pulse is 114, BP 110/70 mmHg and temperature is 37°C. On examination, there is severe tenderness in the lower abdomen with rigidity, guarding and rebound tenderness. Her WBC is 19 and CRP is 170.

27. A 66-year-old woman who has never had penetrative sex has been referred to your clinic with a history of vaginal spotting, visible on wiping. She has an anxiety disorder. Ultrasound scan of her pelvis reveals endometrial thickening to 15 mm and cystic spaces within it. There is also fluid distension of the uterine cavity.

A Perform annual screening for endometrial cancer

B Perform hysteroscopy +/– polypectomy

C Offer levonorgestrel intrauterine system

D Consider changing contraception, if any, then wait and see

E Reassure

F Offer vaginoscopic-approach outpatient hysteroscopy

G Offer hysteroscopy under general anaesthetic

H Offer hysterectomy

I None of the above

Match the most appropriate management to each scenario:

28. A 76-year-old woman with a history of receptor negative breast cancer has recurrent endometrial polyps on scan. She has had these removed twice and is now fed up. Medically, she is not ideally suited for major surgery in view of previous multiple thromboembolic events.

29. A 38-year-old para 1 is seen in your clinic with intermenstrual bleeding. Apart from a proliferative pattern endometrium, there is nothing remarkable on hysteroscopy or histology. She reveals to you that she has been seen at the genetics clinic owing to her family 54 history and diagnosed to have HNPCC (hereditary non-polyposis colorectal cancer syndrome). She is keen to keep her childbearing options open.

30. Conduct a study amongst the doctors who had lung cancer and those who did not in order to compare effect of smoking or no smoking to find the odds of lung cancer.

A.case control
B.meta-analysis
C.prospective cohort
D.retrospective cohort
E.RCT
F.Non randomized clinical trial
G.Cross sectional survey
H.Census
I.Ecological study
J.Qualitative
K.Mixed methods
L.Case report
M.Case series
N.Systematic review

Above options are relevant study design types. Choose appropriate study design for the below scenarios

31. 1000 doctors in a city were recruited, and the data on lung cancer and smoking were collected to compare the effect.

32. You search the literature for RCT done past 5 years and grade the studies on the presence of bias to find the effect of IUCD mirena on heavy menstrual bleeding

33. You search the literature for RCT done past 5 years and grade the studies on the presence of bias and also summarise the effect of individual studies and calculate overall effect of IUCD mirena on heavy menstrual bleeding

34. You conduct a study on those who are taking carboplatin and follow them up for 15 years to find survival rate

35. What is the pre-test probability of the condition?

A.99

B.1.11

C.0.1

D.99.99

E.0.98

F.90

G.10

H.1

I.100

J.99

K.5

L.0.5

M.8

N.0.8

A screening test was conducted to find the diagnostic accuracy of a test. Following table contains the details. Based on this answer the relevant scenarios

36. What are the pre-test odds of disease?

37. What is the positive likelihood ratio of disease?

38. MRS.A attends, routine anomaly scan at 21 weeks, everything is normal except for length of left femur is shorter than right and is below 5th centile Fetal medicine confirms femoral focal deficiency This is not lethal condition Couple have asked for termination inspite Of reassurance as they feel they can’t handle handicapped child

A.confidentiality
B.Autonomy
C.Montogomery ruling
D.Non malfescience
E.Bolam
F.Bolitho
G.Beneficence
H.cant respect autonomy
I.Fraser Guidelines
J.Mental capacity
K. Ashley ruling
L. options B&A
M. options B&D
N. options A.B&C
O. options A,B&I
P. none of the above

39; MR.B. At 34 weeks gestation in her second pregnancy She had previous cesarean section.repeat scan today in antenatal clinic confirms grade 4anterior placenta Previa . Mri has ruled out accreta. She understands she need cesarean section . She is a jehovas witness and doesn’t want blood transfusion

40: A 15 year old who is 10 weeks gestation in her first pregnancy , attends clinic with her elder sister asking for TOP. She wishes to proceed with surgical evacuation .she doesnt want her parents to know.on talking to her she is able to understand , weigh pros and cons of her decision.

41.MRs.X primigravida with 22 weeks pregnancy with Type 3 FGM , Somalian , is accepting defibulation during labour but want reinfibulation at any cost .

42. Mrs. x primigravida delivered by vacuum delivery . consultant Dr, y who explained the consent for vacuum , didn’t explain Facial nerve palsy which is rare complication .But it was difficult delivery which resulted in facial palsy ..Mrs, X is claiming Dr.Y should have given me the fullest possible information or all possible options like cesarean section .she claims doctor is negligent

43.Mrs Brown is 32 years old,32 weeks pregnant.known case of multiple sclerosis.She sees her neurologist every 6 months.All fetal scans are normal so far.

a.advise against pregnancy

b.reassure

c.antacid

d.pulmonary function test

e.full blood count

f.laparotomy

g.cardilogist review

h.acute appendicitis

44.Mrs Smith is a 30 yrs old P0.She has poorly controlled asthma & is on steroids & bronchodilator inhalers regularly.

45.Mrs Louise,is a grand multi at 24 weeks gestation admitted to labour ward with lower abdominal pain & feeling sick for a few days.On exam-abdomen is soft ,lower abdomen tender ,no rebound tenderness & fetal heart positive. VE-os closed with no discharge. Urinalysis shows RBCs++.

46.Mrs Brenda is 22 years old.She has 2 sisters & 1 brother.One sister died suddenly at age of 30.She is thinking of planning a pregnancy.She is fit & fine as of now,but the death of her sister terrifies her.

47.Mrs J is a 30 years old G4P0 at 12 weeks of gestation.She had 3 successive miscarriages at 5,7 & 8 weeks .Her most recent thrombophilia screen has identified lupus anticoagulant antibodies.No personal or family history of venous thrombosis.

a.no intervention

b.aspirin & heparin

c.platelet infusion

d.regular monitoring of platelets

e.splenectomy & caesarean section

f.outlet forceps delivery

g.ventouse delivery

h.low dose aspirin

48.Mrs K is a 35 year old P2.Both children delivered by LSCS.Currently she is pregnant at 28 weeks with satisfactory progress.Her booking investigations & anomaly scan was normal.Her recent blood count at 24 weeks showed platelet count of 90 x 109/L.She is asymptomatic with no personal or family history of bleeding disorder.

49.Mrs D is a 27 year old P0,known to have autoimmune thrombocytopenia for 4 years.She was on prednisolonefor that before conception.She is currently pregnant at 30 weeks.Her progress has not been optimal.Her platelet count at booking was 75X109/L.Since then it has declined constantly.She is on IVIG currently.Recent platelet count is 25X109/L.She has few incidents of bleeding,most recently fresh loss of 40 ml.

50.Mrs Y is a 34 year old G2P1,known to have Von Willebrand type 1 disease.She had a normal vaginal delivery previously.Current pregnancy progress is satisfactory.Latest VWF levels are within normal limits.Admitted with labour pain,got to full dilatation.Was pushing for 90 minutes.CTG showed variable decels with poor recovery.VE revealed head at 2+,OA position,no caput or moulding.

MRCOG Part 2 – Free Grand Mock – Paper 2 – EMQ

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