Answers to Single Best Answer (SBA) questions – part one

Chapter 2

• Q1. Answer: e – When it has been more than 12 months since her last period

Explanation: Menopause can only be diagnosed retrospectively, which is 12 months after the last menstrual period. Symptoms of hot flushes, mood swings and vaginal dryness are common when a woman is ‘perimenopausal’. However, these are suggestive of low levels of estrogen and not specifically for being postmenopausal.

• Q2. Answer: d – The ischial spine

The ischial spines are a pair of bony prominences of the pelvis that can be palpated through the posterior vaginal wall during examination. The station of the presenting part is measured in centimetre in relation to the level of the spine from 0 to –5 above or from 0 to +5 below the spine. It is used as a marker of progression in labour.

• Q3. Answer: d – Mittelschmerz pain

Mittelschmerz is mid-cycle pain caused by the process of ovulation. Commonly, it is a cramping or dull one-sided pain which can continue for 1 to 2 days. This woman is mid-cycle and has no other concerning signs or symptoms; it is the most likely cause ovarian torsion tends to be sudden onset and associated with vomiting. Endometriosis typically causes painful periods and women tend to present with a longer history of pain. Ectopic pregnancy is excluded with a negative pregnancy test. Pelvic inflammatory disease is also possible but is usually associated with vaginal discharge.

Chapter 4

• Q1. Answer: e – Luteinizing hormone

Ovulation is triggered by the mid-cycle surge in luteinizing hormone. It causes rupture of the mature follicle with release of the oocyte.

• Q2. Answer: a – Reassurance

Primary amenorrhoea is only diagnosed once aged 16 years or older. The reassuring points in this case are that she has normal secondary sexual characteristics and a normal body weight. Further investigation is only warranted after the age of 16 years and, even then, with normal secondary sexual characteristics, it is most likely to be a physiological delay.

• Q3. Answer: d – Day 21

If ovulation has occurred, progesterone levels peak 7 days before menstruation, on day 21 of a 28-day cycle. Therefore, this is the best day to measure progesterone levels. This is a commonly used test during fertility investigations. Progesterone is produced by the corpus luteum, which strongly implies that ovulation has taken place.

Chapter 6

• Q1. Answer: c – A miscarriage occurs with no pain or bleeding

Answer a describes an incomplete miscarriage. Answer b is a complete miscarriage. Answer d is a threatened miscarriage. Answer e is recurrent miscarriage.

• Q2. Answer: b – Low molecular weight heparin (LMWH) and aspirin

This woman has antibodies that confirm antiphospholipid syndrome. Untreated, she will have a miscarriage rate of 70% to 80%. Low-dose aspirin and heparin help reduce the risk of miscarriage and obstetric complications related to placental dysfunction. Because of variation between laboratories when testing for anti-phospholipid antibodies, a positive result should be repeated in the same laboratory after an interval of 12 weeks.

• Q3. Answer: a – Conservative management with hCG monitoring

The woman meets the criteria for conservative management as she is stable, pain free with a falling hCG of <1500 IU/L, and the ectopic pregnancy is <35 mm in diameter. All of the options should be discussed with her but she has stated that she would like to avoid intervention if possible. Therefore, conservative management seems to be an appropriate option for her.

Chapter 8

• Q1. Answer: e – Diagnostic laparoscopy

Although pelvic ultrasound and MRI may detect large endometriotic lesions, diagnostic laparoscopy remains the gold standard test and can often provide a tissue diagnosis. Endometrial biopsies and hysteroscopy are used to detect abnormalities in the endometrial lining of the uterus.

Chapter 10

• Q1. Answer: a – Pregnancy and childbirth

All of these answers are potential contributors in the development of pelvic organ prolapse. However, the most common and most likely cause is pregnancy and childbirth, with one-third of women who have had children developing symptomatic prolapse.

• Q2. Answer: c – Stage II

Stage II is when the most distal portion of the prolapse is 1 cm or less proximal or distal to the plane of the hymen. Stage 0 is no prolapse, Stage I is more than 1 cm above the plane of the hymen, Stage III is more than 1 cm below but protrudes no further than 2 cm less than the total vaginal length, and Stage IV is essentially complete eversion of the total length of the lower genital tract (also known as a procidentia).

Chapter 12

• Q1. Answer: c – Ovarian cancer

Symptoms are often insidious in ovarian cancer but common symptoms are abdominal discomfort, bloating, early satiety, loss of appetite and urinary frequency. Her age, nulliparity and smoking history are all risk factors. No change in bowel habit is mentioned; therefore, colon cancer, coeliac disease and constipation are all unlikely. Uterine fibroids tend to present in the reproductive years.

• Q2. Answer: c – Stage Ic

The fact that the cancer is confined to the ovaries makes it Stage I and the finding of positive peritoneal washings makes it Ic. There is no mention of extension to other organs or peritoneal spread; therefore, it does not fit into the Stage II or III classification.