MRCP 1 On examination OG 2015

1.Which of the following drugs should not be prescribed for a breast-feeding mother?

(Please select 1 option)

1 Digoxin
2 Erythromycin
3 Tetracycline CORRECT
4 Theophylline
5 Warfarin

Tetracycline should be avoided in breast-feeding mothers because of staining of the infant's teeth.

Other drugs to be avoided include amiodarone, lithium, chloramphenicol and vitamin A derivatives.

2. Which of the following statements is true regarding smoking in pregnancy?

(Please select 1 option)

1 Dysmorphicfacies is a recognised complication

2 Maternal smoking may adversely affect testicular function in male children
3 Smoking reduces maturation of the fetal lung
4 The newborn baby may require adjustments in drug dosages because of it
5 The reduction in birth weight is related to the number of cigarettes smoked per day Correct

Smoking reduces birth weight which may be of critical importance if the baby is born pre-term.

On average, the babies of smokers weigh 170 g less than non-smokers, but the reduction in birth
weight is related to the number of cigarettes smoked per day.

Smoking is also associated with an increased risk of miscarriage and still birth. The infant has a
greater risk of sudden infant death syndrome.

There is some evidence that maternal smoking may adversely affect ovarian function in female
children.

No dysmorphic syndrome has yet been described.

Maternal smoking has been shown to increase lung maturity, possibily by enhancing the production
or secretion of cortisol. This makes neonates less likely to develop respiratory distress syndrome, but
as lung maturation is often abnormal babies may have reduced lung function and increased rates of
other respiratory illnesses.

Copyright © 2012 Dr Colin Melville

3. Regarding puerperal psychosis which of the following statements is true?

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(Please select 1 option)

1 Often takes the form of schizophrenia

2 Recurrence of puerperal psychosis in subsequent pregnancies is the rule
3 The onset is usually insidious
4 The prognosis is usually good Correct
5 Usually begins after the second week of the puerperium

Puerperal psychosis is a relatively rare complication of childbirth affecting 1-2 per 1000 births.
(Postnatal depression is much commoner affecting 100-150 women per 1000 births).

Puerperal psychosis is a mood disorder with features of loss of contact with reality, hallucinations,
thought disorder and abnormal behaviour. It usually presents rapidly in the first month but most often
starts in the first week.

Prognosis is good.

Reference:

SIGN.Management of perinatal mood disorders.

4. A 17-year-old female attends clinic complaining of hirsuitism and oligomennorhoea.

Which of the following would be most suggestive of a diagnosis of Polycystic Ovarian Syndrome?

(Please select 1 option)

1 Increased androstenedione concentration CORRECT

2 Increased insulin concentration
3 Increased Prolactin concentration
4 Increased FSH concentration
5 Increased Sex Hormone binding globulin (SHBG) concentration

PCOS is associated with a raised LH:FSH ratio, with insulin resistance and hyperandrogenism as
evidenced by raised androstenedione and slightly raised testosterone.

Elevated prolactin concentrations, although a feature of PCOS, is not specific of the diagnosis and
may suggest microprolactinoma.

Although insulin resistance is a feature of PCOS, a raised insulin concentration is rather irrelevant
and no one would measure this in clinical practice. It is often elevated in association with
testosterone secreting tumours.

5. An 18-year-old female presents 12 weeks into an unplanned pregnancy.

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She had been diagnosed with epilepsy six years ago which was well controlled on sodium valproate
and had been taking the combined oral contraceptive pill for three years.

Which of the following is correct concerning this patient?

(Please select 1 option)

1 Lamotrigine should be substituted for sodium valproate

2 She should be advised to have a termination of her pregnancy
3 Sodium valproate interaction with the oral contraceptive increased the risk of pregnancy
4 The dose of sodium valproate should be increased
5 There is an increased risk of a neural tube defect in her fetus Correct

This patient has become pregnant on valproate. This therapy has controlled her seizures and should
not be changed now.

However, there is an increased risk of neural tube defects associated with valproate and this could be
reduced by folate therapy.

Valproate is not an enzyme inducer and unlike other anticonvulsants would not speed up metabolism
of the OCP.

It is entirely up to the individual whether she wishes to pursue the pregnancy or not.

6. An 18-year-old female is reluctant to eat food that is prepared for her.

Which one of the following would be most consistent with a diagnosis of anorexia nervosa?
(Please select 1 option)

1 She believes the food is poisoned

2 She achieves high grades at school CORRECT
3 She has bouts of heavy drinking
4 She regards herself as ill
5 She secretly abuses anabolic steroids

Anorexia nervosa is associated with the abnormal perception of body image. This questions tests
you on the differential diagnoses, and features which may lead you to consider an alternative
diagnosis.
Patients generally feel well despite the protestations of others who think that they look awful.
They exercise avidly and are often high achievers at school or in the workplace.
There is no delusion with regard to the food being poisoned, which may suggest a psychotic
illness.
Heavy drinking would suggest alcoholism.
The secretive abuse of laxatives would fit with the diagnosis rather than anabolic agents.
7. An 17-year-old female presented with a one year history of secondary amenorrhoea. She had
been prescribed temazepam and dihydrocodeine previously.

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On examination she had galactorrhoea to expression. Her prolactin concentration was 6000 mU/L
(50-450). Pregnancy test was negative.

What is the most likely diagnosis?

(Please select 1 option)

1 Drug-induced hyperprolactinaemia
2 Non-functioning pituitary tumour
3 Pituitary microadenoma CORRECT
4 Polycystic ovarian syndrome
5 Turner's syndrome

This patient presents with the classical signs of hyperprolactinaemia, confirmed with the finding of
elevated serum levels of prolactin.

There are a number of different causes of hyperprolactinaemia, and it is useful to classify them as
below:

1. Hypothalamic stimulation:

primary hypothyroidism
adrenal insufficiency.

2 Medications (inhibit dopamine release, leading to reduced inhibition and therefore higher
prolactin release):

Neuroleptics - phenothiazines, haloperidol

Antihypertensives - calcium-channel blockers, methyldopa
Psychotropic agents - tricyclic antidepressants
Anti-ulcer agents - Hs antagonists
Opiates and opiate antagonists.

3. Neurogenic (via autonomic nervous system):

Chest wall injury

Breast stimulation
Breast feeding.

4. Physiological causes (via oestrogen stimulation):

Pregnancy
Coitus
Exercise
Sleep
Stress.

5. Increased prolactin production:

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Ovarian: polycystic ovarian syndrome
Pituitary tumours - adenomas, hypothalamic stalk interruption, hypophysitis

6. Reduced prolactin elimination:

Renal failure
Hepatic insufficiency

The grossly elevated prolactin concentration in this scenario is most suggestive of a

microprolactinoma.

This is not polycystic ovarian syndrome as the hyperprolactinaemia is far too high.

The drugs that she is taking would not cause this level of hyperprolactinaemia.

If she were to have a non-functioning pituitary tumour, stalk compression would be expected to
produce a prolactin concentration of less than 2000 mU/L.

Prolactin levels can be raised in Turner's syndrome, but you would expect some of the other classical
features of the condition to be present.

Further Reading:

1. Melmed S, et al. Diagnosis and treatment of hyperprolactinemia: an Endocrine Society

clinical practice guideline. J ClinEndocrinolMetab. 2011;96(2):273-88.
2. Serri O, et al. Diagnosis and management of hyperprolactinemia. CMAJ. 2003;169(6):575-
81.

8. An 18-year-old female with polycystic ovary syndrome was prescribed metformin.

What is the most important pharmacological action of metformin in this situation?

(Please select 1 option)

1 Increasing gluconeogenesis
2 Increasing insulin levels
3 Increasing luteinising hormone levels
4 Increasing oestradiol levels
5 Increasing peripheral glucose uptake CORRECT

Lowering serum insulin concentrations with metformin ameliorates hyperandrogenism by reduction

of ovarian enzyme activity that results in ovarian androgen production.

Clinical studies have shown that metformin reduces insulin resistance and have demonstrated a fall
in serum androgens, luteinising hormone and weight.

The reduced insulin resistance is associated with reduced insulin drive to the insulin sensitive ovary
in polycystic ovarian syndrome and hence reduces androgen production.

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9. A 29-year-old female who is 22 weeks pregnant is noted to have a blood pressure of 150/90
mmHg on three separate occasions. Urine protein is negative.

Which of the following would be the first line treatment?

(Please select 1 option)

1 Alpha methyldopa CORRECT

2 Atenolol
3 Magnesium sulphate
4 Ramipril
5 Salbutamol

Beta blockers are safe in the third trimester of pregnancy but are generally not used due to fears of
intrauterine growth retardation.

Generally one would favour labetalol in these circumstances, given that there is an evidence base for
its use,but it is not given as an option.

Magnesium sulphate is a recognised treatment for pre-eclampsia, a condition which is not described
here.ACE inhibitors are not in the recommendations

Nifedipine may be used second line.

There is good evidence that methyldopa is effective and safe for both mother and baby in pregnancy.

10. A 29-year-old woman is receiving subcutaneous Clexane (low-molecular weight heparin

[LMWH]) for the treatment of pulmonary embolism. She is 30 weeks pregnant and develops
bruising on her lower arms.

The blood pressure in the left lateral position is 125/75 mmHg.

What is the most appropriate test for this patient?

(Please select 1 option)

1 Factor Xa levels
2 APTT
3 Platelet count CORRECT
4 Serum albumin
5 Serum potassium

This is likely to be heparin-induced thrombocytopenia (HIT).

Long term LMWH treatment has been associated with low platelet counts and this is the test which is
likely to provide you with the most information.

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There are two forms of heparin-induced thrombocytopenia. Type-1 occurs within the first couple of
days of treatment, and resolves spontaneously. It is a direct effect of heparin on platelet activation.

Type 2 HIT is more concerning. It is an immune-mediated disorder which is caused by antibodies to

the heparin-platelet factor 4 complex. It typically occurs later in treatment, and in its most severe
form can be fatal. It should be suspected if the platelet count falls by more than 50% from baseline,
even if the total count remains over 150. It can result in arterial and venous thrombosis. Treatment is
to stop heparin treatment immediately, Neither warfarin or platelet transfusions should be given.

Clexane may cause hyperkalaemia, but this is unlikely to cause bruising.

Albumin levels may increase in pregnancy but serum albumin may be low due to haemodilution.
Again, this would not usually be associated with bruising.

Activated partial thromboplastin time (APTT) is not useful in monitoring LMWH activity, although
APTT may be prolonged in high dose Clexane treatment. APTT is increased in intravenous heparin
treatment, and is used to adjust doses.

Factor Xa levels can be used to monitor efficacy of treatment with low-molecular weight treatment
but the suggestion of bruising here points more to HIT for which Xa levels would not be a useful
guide.

11. Which of the following is the most appropriate anticonvulsant for the treatment of an
eclamptic fit?

(Please select 1 option)

1 Diazepam
2 Lorazepam
3 Magnesium sulphate CORRECT
4 Phenytoin
5 Thiopentone

Magnesium sulphate (MgSO4) is the most effective agent for the treatment of eclampsia and
prophylaxis in severe pre-eclampsia. It can be given intramuscularly (4 g loading, 10 g immediately
and then 5 g every 4 hours in alternating buttocks) or intravenously (4 g followed by maintenance
infusion 1-2 g/hour).

Forty percent remains protein bound, whereas free magnesium ions diffuse into the extravascular
extracellular space, and across the placenta and foetal membranes into the foetus and amniotic fluid.
If levels are carefully monitored, toxicity is low - the first sign is often the loss of the patellar reflex.

The mechanism of action is thought to involve interaction with NMDA receptors.

Reference:

Lu JF, Nightingale CH. Magnesium sulfate in eclampsia and pre-eclampsia: pharmacokinetic

principles.ClinPharmacokinet. 2000;38(4):305-14.

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12. A 31-year-old female with pulmonary hypertension complains of increasing shortness of
breath. She is 36 weeks gestation in her first pregnancy.

Which of the following statements is correct?

(Please select 1 option)

1 Chest x ray is contraindicated

2 Elevated D-dimers rule out PE
3 Enoxaparin dose should be halved in pregnancy
4 Nifedipine is contraindicated in pregnancy
5 Risk of maternal mortality in patients with pulmonary hypertension is 30% Correct

There are multiple causes of shortness of breath in pregnancy, and the patient should be reviewed
both by the medical and obstetric team.

A chest x ray is not absolutely contraindicated in pregnancy, and can be used if the benefits outweigh
the risks.

D-dimers are usually elevated in pregnancy, and are therefore used cautiously when considering the
diagnosis of PE. They should be interpreted in the clinical context, but may be useful if within the
normal range.

The dose of enoxaparin is slightly reduced in pregnancy as dosed per weight, but it is not halved. The
exact dose depends on the weight of the patient, and can be seen in the British National Formulary
(BNF).

Nifedipine is not contraindicated in pregnancy, but should be used judiciously. Labetalol and
methyldopa are the commonest antihypertensives used in pregnancy.

Patients with pulmonary hypertension have a high mortality of at least 30% - some authors put it at
50% - seemingly highest immediately after delivery. Gold standard for diagnosis is right-heart
catheterisation, but echocardiogram can also give useful information. The mainstay of treatment is
with pulmonary vasodilators, but use in pregnancy needs to be discussed with the cardiology and
obstetric team, and a decision made regarding early delivery of the baby.

13. An 18-year-old Asian girl was found to be pregnant after missing her last menstrual period despite
her appropriate use of the oral contraceptive pill for the last two years.

She was found also to have been taking additional medication prescribed by a specialist two months
ago.

Which of the following accounts for the pill failure?

(Please select 1 option)

1 Cimetidine
2 Erythromycin

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3 Isoniazid
4 Ketoconazole
5 Rifampicin Correct

Rifampicin is a hepatic drug-metabolising enzyme inducer.

Thus it enhances the metabolism of oral contraceptive pills, decreasing its effectiveness and resulting
in pill failure.

14. A 31-year-old woman in her third pregnancy is receiving low molecular weight heparin
(LMWH) at treatment doses due to a pulmonary embolism three months prior to conception. She is
currently at 31 weeks gestation.

All fetal scans have been normal, and her blood pressure is 126/80 mmHg in the left lateral position.

Which of the following statements is correct?

(Please select 1 option)

1 Breastfeeding is safe
2 Clexane treatment needs no monitoring in pregnancy CORRECT
3 It is safe for her to receive NSAIDs perinatally
4 Prothrombin time is an indicator of anti-factor Xa activity
5 The dose of Clexane should be increased in the third trimester

There is no recommendation that the dose of LMWH should be increased in the third trimester. The
dose of enoxaparin is altered in pregnancy, but not doubled. The exact dose depends on the weight of
the patient, and can be seen in the British National Formulary (BNF).

Increases in prothrombin time and activated clotting time (ACT) are not linearly correlated with
increasing LMWH anti-thrombotic activity and therefore are unsuitable and unreliable for
monitoring LMWH activity.

Nonsteroidal anti-inflammatory drug (NSAID) treatment increases the risk of haemorrhage in both
mother and fetus.

It is not known whether unchanged enoxaparin sodium is excreted in human breast milk. The oral
absorption of enoxaparin sodium is unlikely. However, as a precaution, lactating mothers receiving
enoxaparin sodium should be advised to avoid breast feeding.

The Royal College of Obstetricians and Gynaecologists (RCOG) have produced guidelines on
Reducing the Risk of Thrombosis and Embolism During Pregnancy and the Puerperium which are
recommended for further reading on this topic.

15. A 26-year-old woman who is 12 weeks pregnant presents with a concern after being exposed
to her mother who has been diagnosed with facial shingles one day ago.

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She was unaware of what the rash was and had examined the rash closely two days ago before her
mother was diagnosed. She informs you that she is unaware of ever having chicken pox.

Which of the following is the most appropriate action that should be taken for this patient?

(Please select 1 option)

1 She should be reassured that she will not contract Varicella zoster from her mother.
2 She should be tested immediately for IgG antibodies to Varicella zoster CORRECT
3 She should be treated with Varicella zoster immunoglobulin
4 She should immediately receive Varicella zoster vaccine
5 She should receive treatment immediately with aciclovir

The patient gives a very good history of exposure to Varicella zoster virus (VZV) and it is possible
for her to acquire chicken pox if she is non-immune.

However, she may well have had VZV infection as a child and the most important action is first to
measure IgG antibodies to VZV. If these are present no further action need be taken and the patient
relatively reassured.

If she is non-immune then the patient will probably need to be treated with VZ immunoglobulin
which has been shown to reduce severity and possible fetal infection.

16. Which of the following should receive treatment with varicella immunoglobulin?

(Please select 1 option)

1 A non-immune pregnant woman who is exposed to her mother who has shingles CORRECT
2 A pregnant woman non-immune to varicella zoster (VZV) exposed to a child with chicken pox 12 days
previously.
3 A pregnant woman previously treated with varicella zoster immunoglobulin 10 days ago who has been re-
exposed to a case of chicken pox.
4 A pregnant woman who has no history of chicken pox but develops shingles in pregnancy
5 A pregnant woman with asthma taking steroids, who has had chicken pox as a child but is now exposed to
her daughter who has chicken pox.

Varicella immunoglobulin is effective if used sufficiently early in patients proven to be non-immune

to VZV and in whom exposure to VZV is confirmed.

The beneficial effects may last up to three weeks following initial treatment and beyond this; it can
be used again should re-exposure occur.

However, it is still important to check VZV antibodies as subclinical disease may have occurred due
to its prior use.

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VZV can be given up to ten days with efficacy following exposure.

Reference:

Royal College of Obstetricians and Gynaecologists (RCOG) Chickenpox in Pregnancy (Green-top

13).

17. A 25-year-old female who is 20 weeks pregnant with her first child is admitted with
palpitations.

The ECG reveals a supraventricular tachycardia (SVT) and this self terminates 20 minutes after
admission. Subsequently she has further runs of symptomatic SVT.

What would be the most appropriate treatment for this patient's paroxysmal supraventricular
tachycardia?

(Please select 1 option)

1 Amiodarone
2 Disopyramide
3 Flecainide
4 Metoprolol Correct
5 Verapamil

Tachyarrhythmias may increase during pregnancy although the causes are not entirely clear.

Regarding the termination of acute SVT, adenosine appears to be safe in pregnancy. In the case of
the prevention of recurrent SVT then verapamil or beta-blockers have data supporting their use.

Current AHA/EHA criteria for the treatment of SVTs in pregnancy do suggest using metoprolol
(level of evidence 1B) rather than verapamil (C), although they recommend avoiding the former in
the first trimester.

18. A 25-year-old female is diagnosed with polycystic ovarian syndrome and commenced on
metformin.

Which of the following are recognised effects of the use of metformin in the treatment of polycystic
ovarian syndrome?

(Please select 1 option)

1 Improves action of vasopressin

2 Improves chances of conception CORRECT
3 Increases exercise capacity
4 Reduces testosterone concentration
5 Reduces weight

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Polycystic ovarian syndrome is recognised to be a condition associated with increased insulin
resistance and metformin is effective through improvements in insulin sensitivity resulting in
ovulation and improvements in hormonal perturbations.

It has been shown to increase rates of conception but has no appreciable effect on weight loss.

19. A fit and healthy couple present with a three year history of first trimester recurrent
miscarriages.

Which of the following tests would be the most appropriate for this couple?

(Please select 1 option)

1 Maternal and paternal karyotyping CORRECT

2 Maternal oral glucose tolerance test
3 Maternal prolactin concentration
4 TORCH screen
5 Vaginal swabs for bacterial vaginosis

Recurrent first trimester miscarriages warrant further investigation which would include karyotyping
and assessment for lupus anticoagulant.

Hyperprolactinaemia may cause subfertility rather than miscarriage.

There is no evidence that gestational diabetes per se causes recurrent first trimester miscarriages.

TORCH (toxoplasmosis, other, rubella virus, cytomegalovirus, and herpes simplex) infection would
be unlikely to precipitate recurrent miscarriage.

Bacterial vaginosis rather than associated with recurrent early miscarriage is associated with second
trimester miscarriage and premature labour.

20. During routine investigation of a healthy couple for primary subfertility semen analysis
reveals azoospermia.

On examination of the male there are no abnormalities on general examination and testicular
examination shows a normal testicular volume.

Investigations reveal:

1 LH 5.1 IU/L (2-10)

2 FSH 4.3 IU/L (2-10)
3 Testosterone 15.3 nmol/L (9-30)

Which of the following is the most likely cause of his azoospermia?

(Please select 1 option)

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1 Androgen insensitivity
2 Genital tract obstruction CORRECT
3 Idiopathic testicular failure
4 Kallman's syndrome
5 Sperm autoimmunity

Azoospermia can occur because of reproductive tract obstruction or inadequate production of

spermatozoa.

It is diagnosed after centrifuged samples of complete semen specimens are analysed microscopically.
History, physical examination and hormone analysis are needed to determine the cause. In less than
10% of cases a testicular biopsy is required to diagnose the cause of azoospermia.

Obstructive azoospermia may be congenital (absence of the vas deferens, idiopathic epididymal
obstruction) or acquired (from infection, vasectomy, trauma).

Couples in whom the man has congenital reproductive tract obstruction should have cystic fibrosis
gene mutation analysis for both partners, as there is a high risk of the male being a CF carrier.

Acquired obstruction of the genital tract can be treated using microsurgical reconstruction.
Alternatively, sperm can be retrieved from the testes and subsequently used for assisted
reproduction.

The cause of non-obstructive azoospermia needs to be identified prior to any treatment.

Androgen insensitivity syndrome results from the inability of cells to respond to androgens.

In males, this can prevent masculinisation of the genitalia and development of secondary sexual
characteristics. You would therefore expect some phenotypic abnormalities, as well as elevated LH
levels.

LH is raised in cases of idiopathic testicular failure.

Kallman's syndrome is hypothalamic gonadotrophin releasing hormone (GnRH) deficiency

associated with hyposmia or anosmia. Serum LH and FDH are low.

Antisperm antibodies can cause 'immune infertility'. Sperm are usually present in semen but are
unable to penetrate the cervical mucus to gain access to the ovum.

Further Reading:

Bohring C, Krause W. Immune infertility: towards a better understanding of sperm (auto)-immunity.

The value of proteomic analysis.Hum Reprod. 2003;18(5):915-24.

Schlegel PN. Causes of azoospermia and their management.ReprodFertil Dev. 2004;16(5):561-72.

21. A 16-year-old girl is diagnosed with Turner's syndrome.

Which of the following autoimmune conditions is most commonly associated with Turner's?

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(Please select 1 option)

1 Addison's disease
2 Autoimmune hepatitis
3 Hashimoto's thyroiditis CORRECT
4 Sjogren's syndrome
5 Vitamin B12 deficiency

Hypothyroidism is quite common occurring in up to 24% of patients with Turner's syndrome.

It is typically autoimmune in origin - Hashimoto's thyroiditis - though the exact explanation for its
high prevalence is not known.

Reference:

Livadas S, Xekouki P, Fouka F, et al. Prevalence of thyroid dysfunction in Turner's syndrome: a

long-term follow-up study and brief literature review.Thyroid. 2005;15(9):1061-6.

22. A 28-year-old female returns from a trip to Bangladesh with a fever, diarrhoea and rash. She is
diagnosed with typhoid fever.

However, she has a 1-month-old infant and wishes to continue to breast feed.

Which of the following antibiotics is the most appropriate therapy for her?

(Please select 1 option)

1 Ceftriaxone CORRECT
2 Chloramphenicol
3 Ciprofloxacin
4 Cotrimoxazole
5 Gentamicin

Typhoid fever is best treated with quinolones, chloramphenicol or cotrimoxazole.

However, with breast feeding chloramphenicol is relatively contraindicated as are quinolones due to
potential risk even if small.

Also cotrimoxazole is safe in breast feeding except with infants less than 2 months due to possible
risk of increased bilirubin.

In pregnancy or children the drug of choice is parenteral ceftriaxone.

23. A 22-year-old woman presented with hirsuitism and oligomenorrhea for the last five years. She
is an accountancy trainee and does not want to conceive at least for the next couple of years. She is

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very anxious about her irregular menses and is especially worried as her mother was diagnosed
with uterine cancer recently.

Examination is essentially normal apart from coarse dark hair being noticed under her chin and over
her lower back.

Investigations during the follicular phase:

A Serum androstenedione 10.1 nmol/L (0.6-8.8)

B Serum dehydroepiandrosteronesulphate 11.6 µmol/L (2-10)
C Serum 17-hydroxyprogesterone 5.6 nmol/L (1-10)
D Serum oestradiol 220 pmol/L (200-400)
E Serum testosterone 3.6 nmol/L (0.5-3)
F Serum sex hormone binding protein 32 nmol/L (40-137)
G Plasma luteinising hormone 3.3 U/L (2.5-10)
H Plasma follicle-stimulating hormone 3.6 U/L (2.5-10)

What is the most appropriate treatment?

(Please select 1 option)

1 Combined OCP CORRECT

2 Finasteride
3 Metformin
4 Progesterone only pill
5 Spironolactone

This young woman has typical features of polycystic ovary syndrome (PCOS) with supportive
biochemistry elevated androstendione, normal oestradiol and 17OHP.

She wants treatment of her hirsutism, does not want to fall pregnant and the most appropriate therapy
would be the combined oral contraceptive pill (OCP) such as Dianette.

24. A 23-year-old female presents 16 weeks into her pregnancy with a vaginal discharge. Further
investigation confirms infection with Chlamydia trachomatis.

Which of the following is the most appropriate treatment for this patient?

(Please select 1 option)

1 Ciprofloxacin
2 Cotrimoxazole
3 Doxycycline

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4 Erythromycin Correct
5 Metronidazole

C. trachomatis infection is increasingly common in the UK and is associated with adverse fetal
outcome including spontaneous miscarriage, premature rupture of membranes and intrauterine
growth retardation (IUGR).

In the UK treatment is advised ahead of test results if chlamydia is strongly suspected clinically.
Current UK guidelines recommend three different options in pregnancy:

Erythromycin 500 mg QDS for 7 days or BD for 14 days

Amoxicillin 500 mg TDS for 7 days
Azithromycin 1 g stat - the BNF cautions that this should only be used if there are no
alternatives. However, guidelines seem to vary in their recommendation of azithromycin with
many advocating its use as a stat dose

In the actual examination you would not be expected to decide between erythromycin and
azithromycin based on varying opinions, so we have avoided including azithromycin and amoxicillin
in the list of question options for this reason.

Therefore, of the options given above, erythromycin is the most appropriate option.

Doxycycline can be used in non-pregnant patients (100 mg BD for 7 days), but is not appropriate
here. Co-trimoxazole and metronidazole are not routinely used in the treatment of chlamydia.

Also important to note is the recommendation that pregnant patients be tested for cure, 5 weeks after
completing treatment (or 6 weeks if azithromycin is used).

25. A 51-year-old lady enquires about taking hormone replacement therapy (HRT).

Which of the following is the most compelling indication for taking HRT?

(Please select 1 option)

1 Control flushing CORRECT

2 Prevent Alzheimer's disease
3 Prevent ischaemic heart disease
4 Prevent osteoporosis
5 Reverse vaginal atrophy

The indications for HRT have been a matter of great debate over recent years.

Relieving the symptoms of menopause is the most compelling indication. There has been discussion
about whether it also results in the other benefits set out in the question stem but the evidence is
mixed.

26. A 50-year-old female presents with concerns related to reduced libido. This has been causing
problems with her husband and she feels rather down.
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In her past history she has had ovarian failure associated with a hysterectomy three years ago and is
being treated with oestradiol 2 mg daily.

Which of the following would be the most appropriate treatment for this patient?

(Please select 1 option)

1 Add fluoxetine
2 Add norethisterone
3 Add testosterone patch
4 Counselling& lifestyle changes
5 Optimiseoestrogen replacement Correct

Hypoactive sexual desire disorder is well recognised in post-menopausal females as well as in

patients following ovarian failure.

Counselling and lifestyle changes are generally only successful in isolation if the primary cause is
relationship issues or stress.

Depression may need treatment if it is the primary cause, but some antidepressants have been
associated with loss of libido and therefore would not be the first cause in this case.

If a woman's hormones are thought to be inadequate, as in this case, then hormone replacement
therapy (HRT) should be optimised but with the same caveats and precautions as at any other time.
The value of androgen patches for treating hormone-deficient men is controversial, and even more so
in women, and may have detrimental effects on the liver and cholesterol. An opinion from secondary
care would probably be wise.

Progestogens are not required in hysterectomised subjects and may cause a deterioration in
symptoms.

27. A 25-year-old woman is admitted on the medical intake.

She is 10 weeks post partum and has been generally unwell for two weeks with malaise sweats and
anxiety.

On examination she is haemodynamically stable, and clinically euthyroid.

TFTs show the following:

A Free T4 33 pmol/L (9-23)

B Free T3 8 nmol/L (3.5-6)
C TSH <0.02 mU/L (0.5-5)

What is the appropriate management?

(Please select 1 option)

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1 Carbimazole 40 mg/day
2 Lugol's iodine
3 Propranolol 20 mg tds CORRECT
4 Propylthiouracil 50 mg/tds
5 Radioactive iodine therapy

The diagnosis here is likely to be post partum thyroiditis which tends to occur within the three
months of delivery followed by a hypothyroid phase at three to six months, followed by spontaneous
recovery in one third of cases. In the remaining two-thirds, a single-phase pattern or the reverse
occurs.

Management is centred on symptomatic treatment using beta-blockers for relief of tremor or anxiety,
and observation for the development of persistent hypo- or hyperthyroidism.

Graves' disease is a less likely diagnosis based on the proximity to delivery and the absence of any
other signs to suggest Graves' ophthalmopathy, goitre and bruit.

Hashitoxicosis is a possibility but is less likely than Graves'.

Further Reading:

NICE Clinical Knowledge Summaries. Hyperthyroidism - Management

28. A 17-year-old primigravida complains of constipation and arthralgia at 28 weeks gestation.

A number of biochemical investigations are performed, but which of these is clinically significant?

(Please select 1 option)

1 Detectable urinary human chorionic gonadotrophin

2 Free thyroxine 8.9 pmol/L (9 - 22)
3 Prolactin of 1000 mU/L (<450)
4 Serum alkaline phosphatase of 350 iu/L (50 - 110)
5 Serum corrected calcium 2.89 mmol/L (2.2 - 2.6) Correct

This patient has symptoms suggestive of hypercalcaemia, which are clinically significant.

Free T4 is at the lower end of the normal range which is often the case in pregnancy and TSH is a
better guide of thyroid function.

Hyperprolactinaemia is a normal finding in pregnancy, as is detectable urinary human chorionic

gonadotrophin.

It is also normal for serum alkaline phosphatase to rise by up to four times normal due to increased
placental production.

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29. A 32-year-old woman comes to her 20 week visit in her first pregnancy.

You are asked to review her as she is hypertensive, with a BP of 162/102 mmHg. Her BP at booking
was also elevated at 141/91 mmHg. She has no significant past medical history of note apart from
having consulted the practice nurse at the surgery for weight loss counselling over the past few years.

On examination she looks well, physical examination being consistent with a 20 week pregnancy.

Investigations show

A Haemoglobin 110 g/L (115-160)

B White cell count 5.1 ×109/L (4-10)
C Platelets 189 ×109/L (150-400)
D Sodium 140 mmol/L (134-143)
E Potassium 4.2 mmol/L (3.5-5)
F Creatinine 89 mol/L (60-120)
G Glucose 5.0 mmol/L (<6.0)
h Urine Blood and protein negative

Which of the following is the most appropriate antihypertensive medication for her?

(Please select 1 option)

1 Atenolol
2 Hydrochlorothiazide
3 Methyldopa CORRECT
4 Ramipril
5 Valsartan

Methyldopa is the treatment of choice for hypertension in pregnancy, as it has the largest evidence
base for use.

Labetalol (alpha- and beta-blocker) is recommended as first line in the NICE guidelines on
Hypertension in pregnancy (CG107), however methyldopa or nifedepine may be used.

Angiotensin converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARBs) are not
recommended for use in pregnancy because of concerns about teratogenicity, particularly with
respect to abnormalities of the renal tract (second/third trimester) cardiovascular and neurological
(first trimester).

As such, patients who are using ARBs or ACE inhibitors should change their medication prior even
to trying to become pregnant.

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This patient has a blood pressure of >160 mmHg, this puts her in the category of severe
hypertension, requiring inpatient care and reduction of blood pressure to <150/90 mmHg.

30. A 22-year-old woman has come to the clinic complaining that she has had no periods for the
past four months. She was always a normal weight, but has found it difficult to maintain her size
since starting intensive training to run a marathon. She takes no regular medication.

On examination her BMI is 18 kg/m2. Physical examination, including assessment of secondary

sexual characteristics is unremarkable.

Investigations show

A Haemoglobin 114 g/L (115-165)

9
B White cell count 6.9 ×10 /L (4-11)
9
C Platelets 203 ×10 /L (150-400)
D Sodium 140 mmol/L (135-146)
E Potassium 4.2 mmol/L (3.5-5)
F Creatinine 102 mol/L (79-118)
G Albumin 40 g/L (35-50)
H Alanine amino transferase 10 U/L (5-40)
I Follicle stimulating hormone 15 IU/L (<20)
J Thyroid stimulating hormone 2.5 mU/L (0.5-5.0)

Which of the following is the most likely diagnosis?

(Please select 1 option)

1 Autoimmune ovarian failure

2 Pregnancy
3 Prolactinoma
4 Secondary amenorrhoea due to weight loss CORRECT
5 Thyrotoxicosis

Given this woman has been intensively training and has a BMI of 18, it seems most likely that she
has amenorrhoea related to weight loss.

FSH is in the normal range, which counts against autoimmune ovarian failure; we have no signs at
all that she is pregnant, and she does not report symptoms consistent with prolactinoma, such as
vaginal dryness or breast leakage of milk.

Additionally her TSH is in the normal range, which rules out thyrotoxicosis.

31. A 32-year-old woman presents to the clinic in a very distressed state.

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She is 35 weeks pregnant with her first child. Apparently she has developed a crop of herpetic ulcers
over her vulva and on further questioning her husband admitted to unprotected sex with a prostitute
during a business trip. The ulcers are confirmed as containing herpes simplex virus and serology
suggests that this is a primary infection.

Which of the following represents the correct management with respect to the delivery of her child?

(Please select 1 option)

1 Aciclovir cover is not recommended in any circumstances for the mother during delivery
2 Aciclovir is not recommended in any circumstances for the infant during the post partum period
3 She can be left to make up her mind about the mode of delivery
4 She should have a caesarean section Correct
5 She should have a vaginal delivery

She should have a caesarean section.

RCOG guidance is clear that when primary herpes infection occurs within six weeks of expected
delivery then caesarean delivery is the recommended course of action.

Additionally, IV aciclovir cover for mother and infant during the peri-partum period is recommended
if a vaginal delivery should occur.

If vaginal delivery occurs in the absence of aciclovir cover, an analysis of five available studies
suggests that the neonatal infection rate maybe up to 41%.

32. A 34-year-old woman comes to the Emergency department GP complaining of intermenstrual

bleeding, particularly after sexual intercourse, pain on intercourse and intermittent severe right iliac
fossa pain.

In the last month she was admitted to the Emergency department with suspected appendicitis but
later discharged.

On examination she is pyrexial 37.9°C and there is bilateral lower abdominal tenderness. Speculum
examination reveals cervicitis and mucopurulent cervical discharge.

Which of the following represents the most appropriate antibiotic regime?

(Please select 1 option)

1 Ceftriaxone 500 mg IM then doxycycline 100 mg BD and metronidazole 400 mg BD for 14 days CORRECT

2 Cephalexin 500 mg BD and metronidazole 400 mg PO BD for 14 days

3 Metronidazole 400 mg PO BD for 7 days
4 Metronidazole 400 mg PO BD for 14 days and ciprofloxacin 500 mg BD for 14 days
5 Ofloxacin 400 mg BD for 7 days

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This patient has symptoms consistent with pelvic inflammatory disease, which may be sexually
transmitted and due to either Chlamydia or gonorrhoea. Antibiotic treatment should not wait for
swab or culture results and be commenced once the diagnosis is made.

Current guidelines for the outpatient treatment of pelvic inflammatory disease recommend
ceftriaxone 500 mg IM STAT, followed by oral doxycycline 100 mg BD and metronidazole 400 mg
BD for 14 days.

Referral to a GUM clinic should be considered to arrange screening across the range of possible
sexually transmitted infections.

Long term sequelae include possible tubal scarring and subfertility.

33. A child-bearing woman asked you about the use of angiotensin converting enzyme (ACE)
inhibitor in pregnancy.

Choose the best answer in response to her query.

(Please select 1 option)

1 ACE inhibitors are listed as FDA rating B; they can be used in pregnancy
2 ACE inhibitor should be changed to angiotensin receptor blocker before conception
3 ACE inhibitor should be withheld during the first trimester; it is otherwise safe in the second and third
trimester
4 ACE inhibitor should not be used during pregnancy CORRECT
5 The drugs can be continued until second trimester because ACE inhibitor has not been shown to be
teratogenic

Avoidance of ACE inhibitors at any stage of pregnancy is recommended.

Contrary to previous teaching, a United States study (including 29,507 infants born between 1985
and 2000, 209 of whom were exposed to ACE inhibitors in the first trimester only) showed a
significant increase in major (in particular, cardiovascular) congenital malformation.

Advising that the drugs can be continued until second trimester is therefore incorrect. As a result of
this study (published in the New England Journal of Medicine) the FDA changed their ratings of
ACE inhibitors to category C for the first trimester and category D during the second and third
trimesters.

Category C states: 'Animal reproduction studies have shown an adverse effect on the fetus and there
are no adequate and well-controlled studies in humans, but potential benefits may warrant use of the
drug in pregnant women despite potential risks'.

Category D states: 'There is positive evidence of human fetal risk based on adverse reaction data
from investigational or marketing experience or studies in humans, but potential benefits may
warrant use of the drug in pregnant women despite potential risks'.

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Second and third trimester exposure to ACE inhibitors must be avoided because of the association
with serious adverse fetal effects, notably oligohydramnios, in utero death, and neonatal anuria and
renal failure.

The same probably applies to angiotensin receptor blocker and direct renin inhibitor (aliskiren).

34. A 35-year-old gentleman with well controlled rheumatoid arthritis has, with his wife, been trying
to conceive for 18 months. He and his wife visit you in fertility clinic.

What is the likely cause of their problem?

(Please select 1 option)

1 Chloroquine
2 Chronic illness reducing fertility
3 Leflunomide CORRECT
4 Methotrexate
5 Reduced fertility due to female pelvic inflammatory disease

Leflunomide reduces sperm count.

Chronic illness can affect fertility; however in this case the gentleman's rheumatoid arthritis is well
controlled and therefore should not be a barrier to conception.

Chloroquine is safe in pregnancy and does not affect fertility. Its side effects include gastrointestinal
disturbances and headaches.

Methotrexate does not affect fertility but should be avoided in pregnancy. Its more serious side
effects are bone marrow suppression and hepatotoxicity, hence blood monitoring required.

Female related problems are the most common cause of infertility, especially pelvic inflammatory
disease, secondary to infection. However in this case a good drug history will point to other causes.

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