EMQ paper 1- Answers

Option list
A
B
C
D
E
F
G
H
I
J

anterior repair
endometrial ablation
perineorrhaphy
physiotherapy
posterior repair
ring pessary
sacrospinous fixation
tension-free vaginal tape
total abdominal hysterectomy
vaginal hysterectomy and pelvic floor repair

Instruction: For each scenario described below choose the SINGLE most
likely management option from the above list of options. Each option may
be used once, more than once, or not at all.
1. A 62 year old woman presents with a 12 month history of noticing a
lump coming down below. She has no past medical history of note
and has previously had 4 vaginal deliveries. On vaginal examination,
she has a complete procidentia.
Answer J
2.

vaginal hysterectomy and pelvic floor repair

An 85 year old woman is referred to the outpatient clinic with

a history of urinary frequency and difficulty emptying her bladder
completely. She is hypertensive and diabetic with a BMI of 38. On
speculum examination she has a large cystocoele and significant
uterine descent.

Answer F ring pessary

3. A 58 year old, sexually active, woman complains of a ballooning of
tissue through the vaginal opening when she stands for long periods
of time. She had a vaginal hysterectomy 15 years previously for
dysfunctional uterine bleeding. On examination, she has a vault
prolapse.
Answer G sacrospinous fixation

Option list
A
B
C
D
E
F
G
H
I
J

Conservative management
Cornual resection
Cornual resection with dye test
Methotrexate intramuscularly
Methotrexate orally
Mifepristone and misoprostol
Salpingectomy
Salpingo-oophorectomy
Salpingostomy
Tubal injection of potassium chloride

Each of the following clinical scenarios below relate to women with

complications of early pregnancy. For each patient select the single most
appropriate management option from the list above. Each option may be
used once, more than once or not at all.
4. A 28 year old woman in her third planned pregnancy was referred to
the Early Pregnancy Assessment Unit. She has had two previous
caesarean sections and is now 6-7 weeks gestation with a two day
history of left iliac fossa pain and dark vaginal bleeding. An
ultrasound scan showed an empty uterus, left adnexal mass and
the serum BhCG level was 3,500 iu. She agrees to a laparoscopy.
The findings are: normal uterus, both ovaries and right tube, left
tube distended by an unruptured ectopic pregnancy 4x5cm in
diameter. There is blood trickling from the fimbrial end and
approximately 200 ml of blood in the pouch of Douglas.
Answer G Salpingectomy
5. A 24 year old woman is seen in the Early Pregnancy Unit at 7 weeks
gestation with right sided pain and a transvaginal scan has shown
an empty uterus with a right sided adnexal mass. She had been
trying to conceive for 18 months. The serum BhCG was 2,500 iu and
48 hours later was 2900 iu. At laparoscopy there is an unruptured
right ectopic; the left tube has clubbed fimbriae and filmy adhesions
to the left ovary. You also note perihepatic adhesions.
Answer I Salpingostomy
6. A 25 year old woman presents with right sided pain and bleeding to
the Early Pregnancy Unit at 7-8 weeks gestation in her second
pregnancy. The first pregnancy resulted in a forceps delivery with a
retained placenta and postnatally she received antibiotics for
endometritis. A scan has shown an empty uterus with a 3x4cm right
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adnexal mass with a gestation scan, fetal pole and fetal heart seen
within the mass. The serum BhCG level is 4,800 IU, she is very
reluctant to consider surgery as she really wants more children.
Answer I Salpingostomy

Option list
A
B
C
D
E
F
G
H
I
J
K
L
M

Cancel the operation

Cancel the operation and arrange ultrasound scan
Cancel the operation and refer to anaesthetist
Cancel the operation and refer to general practitioner
Cancel the operation and refer to consultant physician
Contact the on call gynaecology consultant
Defer the operation and discuss with multidisciplinary team
Defer the operation for 4 weeks
Defer the operation for 6 months
Defer the operation till she has completed a course of
antibiotics
Proceed with antibiotic cover
Proceed with the operation as an emergency
Proceed with operation as planned

Each of the following clinical scenarios below relate to a woman scheduled

for gynaecological surgery in the following week. In each case you are the
ST5 in the pre-admission clinic and you are asked to make the most
appropriate decision about the operation in light of the clinical situation.
For each patient select the single most appropriate decision from the list
above. Each option may be used once, more than once or not at all.
7. A 24 year old woman was seen in clinic three months ago with right
iliac fossa pain and an ultrasound scan had shown a 4x5cm right
ovarian cyst. She tells you her pain has significantly improved over
the last month.
Answer B Cancel the operation and arrange ultrasound scan
8. A 28 year old woman has prolonged heavy periods and a single
large fibroid measuring 9x9cm. Her family is not complete and she
has been listed for a myomectomy. Her haemoglobin is 9.0 g/dl.
Answer A Cancel the operation

Option list
A
B
C
D
E
F
G
H
I
J
K
L
M
N
O
P
Q
R
S

Aim for normal vaginal delivery

Continue syntocinon and reassess in 2 hours
Continue syntocinon and reassess in 4 hours
Delivery by category 1 lower segment caesarean section
Delivery by category 2 lower segment caesarean section
Delivery by category 3 lower segment caesarean section
Delivery by category 4 lower segment caesarean section
Fetal scalp pH measurement in 20 minutes
Fetal scalp pH measurement in 60 minutes
Manual rotation and forceps delivery in the delivery room
Manual rotation and forceps delivery in theatre
Mid cavity forceps delivery in the delivery room
Mid cavity forceps delivery in theatre
Outlet forceps delivery in the delivery room
Outlet forceps delivery in theatre
Rotational forceps delivery in the delivery room
Rotational forceps delivery in theatre
Ventouse delivery in the delivery room
Ventouse delivery in theatre

The midwife calls you to see a woman on the labour ward. For each
patient select the single most appropriate management from the list
above. Each option may be used once, more than once or not at all.
9. A 40 year old primigravida who conceived after three cycles of IVF is
now at 39 weeks gestation. Labour commenced spontaneously 12
hours ago with spontaneous rupture of the membranes. Intravenous
oxytocin was commenced four hours ago as the cervix had
remained 4cm dilated for four hours. The cardiotocography is
reassuring and the liquor remains clear. The midwifery staff are
concerned as she has been pushing involuntarily and ask you to
assess her. The fetal head is 2/5 palpable per abdomen. The cervix
is 5cm dilated, the vertex is -1 above the spines with caput +++
and moulding ++.
Answer F Category 3 caesarean section
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10.
A 40 year old primigravida who conceived after three cycles of
IVF is now at 39 weeks gestation. Labour commenced
spontaneously 12 hours ago with spontaneous rupture of the
membranes. Intravenous oxytocin was commenced four hours ago
as the cervix had remained 4cm dilated for four hours and an
effective epidural with a dense block is in place. The midwives ask
you to review the cardiotocogram which shows reduced variability
and atypical variable decelerations with 75% of contractions for the
last 20 minutes. The head is 0/5 palpable per abdomen and vaginal
examination shows the cervix to be fully dilated, the vertex is +2
below the spines and is in the direct occipito-anterior position. The
liquor is now meconium stained.
Answer N

Outlet forceps delivery in the delivery room

Option list
A
B
C
D
E
F
G
H
I
J
K

Aspirin 75mg
Clopidogrel
Fondaparinux
Hydration and early mobilisation
Intermittant lower limb compression device
Low molecular weight heparin prophylaxis dose
Low molecular weight heparin treatment dose
None needed
Rivaroxaban
Unfractionated heparin intravenously
Warfarin

For each following clinical scenarios you are asked to carry out a risk
assessment for thromboembolic disease. For each patient select the most
SINGLE most appropriate intervention. Each option may be used once,
more than once or not at all.
11.
A primiparous woman is re-admitted to the postnatal ward 7
days after a forceps delivery for prolonged second stage. She had a
third degree tear sutured in theatre under general anaesthetic as
the epidural wasnt working well. She is complaining of pain and
swelling of her left calf.
Answer G LMWH treatment dose
12.
A 25 year old woman had an emergency caesarean section for
failure to progress after a labour of 18 hours. The epidural catheter
was removed six hours ago. Her body mass index is 32.
Answer F LMWH prophylaxis dose
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Option list
A
B
C
D
E
F
G
H
I
J
K
L

Amniotic fluid embolism

Eclampsia
Epileptiform seizure
Diabetic ketoacidosis
High spinal tap
Myocardial infarction
Placental abruption
Post-partum haemorrhage
Puerperal septic shock
Pulmonary embolism
Sub-arachnoid haemorrhage
Uterine rupture

Instruction: For each scenario described below choose the SINGLE most
likely diagnosis from the above list of options. Each option may be used
once, more than once, or not at all.
13.
A 26 year old woman underwent a caesarean section in her
first pregnancy for fetal distress. This current pregnancy was
uneventful and she went into spontaneous labour. She requested an
epidural for analgesia at 7 cm dilatation. Shortly following the
insertion of the epidural the fetal heart rate pattern became
pathological.
Answer L uterine rupture

14.
An un-booked woman was admitted via ambulance
unconscious. The only history available is that she was feeling
unwell for the previous few days with headaches and had collapsed
at home shaking. On examination, she was unconscious, there
was an abdominal mass consistent with a 24 week pregnancy, her
blood pressure was 180/110 mmHg and urinalysis revealed
proteinuria.
Answer B eclampsia

Option list
A
B
C
D
E
F
G
H
I
J
K
L
M
N
O
P

Cervical adenocarcinoma
Cervical squamous carcinoma
Cervical intraepithelial neoplasia
Cholelithiasis
Endometrial carcinoma
Endometrial hyperplasia
Endometrial stromal sarcoma
Fallopian tube carcinoma
Fibroid
Irritable bowel syndrome
Leiomyosarcoma
Metastatic breast adenocarcinoma
Ovarian carcinoma
Primary lymphoma of the uterus
Vulval carcinoma
Vulval intraepithelial neoplasia

Instruction: For each scenario described below choose the SINGLE most
likely diagnosis from the above list of options. Each option may be used
once, more than once, or not at all.
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15.
A 45 year old woman is known to carry the BRCA -1 gene. She
presents with a 6 month history of upper abdominal discomfort,
abdominal swelling and breathlessness.
Answer M ovarian carcinoma
16.
A 75 year old woman presents with post-menopausal
bleeding. On examination she has an ulcerated vulval lesion 2cm in
diameter.
Answer O vulval carcinoma
17.
A 67 year old returns to your clinic with recurrent postmenopausal bleeding and vaginal discharge. She has had two
hysteroscopies in the last 6 months which were normal apart from
atrophic changes. Ultrasound scans of the pelvis have also been
normal.
Answer H fallopian tube carcinoma

Option list
A
B
C
D
E
F
G
H
I
J
K

1
1
1
1
1
1
1
1
1
1
1

in
in
in
in
in
in
in
in
in
in
in

1
2
5
10
20
25
100
150
200
500
1000

Each of the following clinical scenarios below relate to women seeking

pre-conception advice. For each patient select the SINGLE most
appropriate answer from the list above. Each option may be used once,
more than once or not at all.
8

18.
A couple have had three children, two of which have had
congenital heart disease. They ask your advice about the chance of
a further pregnancy being similarly affected by congenital heart
disease.
Answer D 1 in 10
19.
A 28 year old woman had an open spina bifida lesion closed in
the early neonatal period and subsequently she relies on a
wheelchair for mobility and intermittent self catheterisation. She is
seeking your advice about the chance of her having a baby similarly
affected by a neural tube defect.
Answer F 1 in 25
20.
A 39 year old woman has a long history of infertility and is
contemplating assisted conception treatment. She asks you what is
the risk of having a baby with trisomy 21 at her age?
Answer H 1 in 150