7 - Pharmacology (BusySPR 2016 SBAs)

This Copy is for Dr.
Mohamed ElHodiby
Question 1 Which one of the above drugs is an anti-fibrinolytic agent?
Options for Questions 1-1
A Spironolactone B Aspirin
C Indomethacin D Tranexamic acid
E GnRH
A(Correct answ er: D)
Explanation
Tranexamic acid
• Anti-fibrinolytic agent - reduces menstrual loss by ~50% and is more effective than NSAIDS.
• Effective in reducing menstrual loss associated with IUCD, fibroids and bleeding diathesis.
• Not to be used in women with irregular bleeding until underlying pathology has been excluded
Contraindications
Thrombo-embolic disease
Side effects
• Nausea, vomiting, diarrhoea
• Disturbance in colour vision - discontinue therapy
• Thrombo-embolic events
Which one of the above drugs is effective in the treatment of heavy menstrual bleeding and can
Question 2
cause renal failure?
A Tranexamic acid B Mefenamic acid

C Raloxifene D Tamoxefen
E Clomiphene citrate
A(Correct answ er: B)
Explanation
NSAIDS
• Mefenamic acid commonly used, reduces menstrual loss by ~25%
• Better side-effect profile compared to tranexamic acid.
• Also effective in IUCD associated menorrhagia
• Effective treatment for dysmenorrhoea
• Long-term use may be associated with reduced fertility
• Should be used with caution in women with renal or cardiac impairment
Contraindications
• Hypersensitivity to aspirin or other NSAIDs including asthma, angioedema and urticaria
• Pregnancy / breastfeeding
• Bleeding disorders
• Previous or active peptic ulcer disease
• Avoid if renal impairment
Side-effects
• GI discomfort, nausea, diarrhoea
• GI bleeding & ulceration
This Copy is for Dr. Mohamed ElHodiby

• Hypersensitivity including asthma, rash, angioedema
• Renal failure
Tranexamic acid
Contraindications
• Thrombo-embolic disease
Side effects
Question 3 Which one of the above statements regarding mefenamic acid is true?
Reduces menstrual blood loss by ~50% in women

A Is an anti-fibrinolytic agent B
with heavy menstrual bleeding
Is ineffective in copper IUCD associated heavy Is associated with reduced fertility with long-term
C D
menstrual bleeding use
E Is associated with hot flushes
Explanation
NSAIDS
Contraindications
Side-effects
• Renal failure
Question 4 Which one of the above statements about danazol is true?
Is contraindicated in women with a history of

A Is effective in treating idiopathic hirsutism B
thrombo-embolic disease
C Is recommended for use for up to 5 years D If taken in during pregnancy can emasculate a

male fetus
Is associated with proliferation of the
E
endometrium
Explanation
Danazol
• Synthetic androgen with anti-oestrogenic and anti-progestogenic activity; inhibits pituitary gonadotrophin release and
has direct suppressive effect on endometrium.
• Reduces menstrual loss but is associated with androgenic side-effects: weight gain of 2-4kg with 3 months treatment,
acne, hirsutism, seborrhoea, irritability, musculoskeletal pains, fatigue, hot flushes and breast atrophy
• These side effects are reversible on discontinuation of therapy - voice changes may occur and may not be reversible.
• Women must be advised to use barrier contraception as danazol can virilise a female fetus if pregnancy occurs.
• The recommended duration of treatment is up to 6 months
Contraindications
• Pregnancy – virilise female fetus
• Breastfeeding
• Severe hepatic, renal and cardiac disease
• Androgen-sensitive tumours
Which one of the above drug acts on the anterior pituitary gland to reduce menstrual blood
Question 5
loss?

C Clomiphene citrate D Cyproterone acetate
E GnRH analogue
A(Correct answ er: E)
Explanation
GnRH analogues
• Initial administration of GnRH (Gonadorelin) analogues results in stimulation of gonadotrophin (FSH & LH) release
• Continued administration results in down-regulation of GnRH receptors in the anterior pituitary and a reduction in
FSH and LH release
• This results in anovulation and a medically induced menopausal state
• Result in amenorrhoea, menopausal symptoms and loss of bone mineral density with prolonged use (over 6 months)
Indications
• Treatment of endometriosis
• Treatment of infertility
• Treatment of menorrhagia due to uterine fibroids prior to hysterectomy or myomectomy
• Induction of endometrial atrophy prior to endometrial resection or ablation
• Treatment of precocious puberty
• Treatment of hormode-dependent tumours in males and females (such as prostate cancer and breast cancer)
• Therapeutic trial in women with severe pre-menstrual syndrome prior to bi-lateral oophorectomy
Administration
• By nasal spray (Buserelin, Nafarelin)
• By sub-cutaneous injection into anterior abdominal wall (Goserelin)
• By sub-cutaneous or intra-muscular injection (Leuporelin acetate)
Side-effects
• Menopausal symptoms – hot flushes, vaginal dryness, dyspareunia, loss of libido
• Loss of bone density – reduced by treatment with oestrogen +/- progestogen or tibolone

• Headache
• Nasal irritation with spray formulations
• Ovarian cysts
Question 6 Which one of the above statements regarding GnRH analogues is true?
Should not be used on their own for longer than 6

A B Result in supra-anovulation with long-term use
weeks
C Are associated with loss of bone mineral density D Are typically administered orally
E Relieve hot flushes
A(Correct answ er: C)
Explanation
GnRH analogues
FSH and LH release
Indications
Administration
Side-effects
• Headache
• Ovarian cysts
Question 7 Which one of the above statements regarding tamoxifen is true?
Has anti-oestrogenic effects on the post-

A Is an anti-progestogen B
menopausal uterus
Can be used to induce ovulation in women with
C Reduces the risk of endometrial hyperplasia D
anovulatory infertility
E Can be used to treat hot flushes

Explanation
TAMOXIFEN
Action
Blocks oestrogen receptors in the breast
Has anti-oestrogenic effects on the pre-menopausal uterus
However, has oestrogenic effects on the post-menopausal uterus, increasing the risk of endometrial hyperplasia
and carcinoma
Clinical use
Secondary prevention of breast cancer, making use of its anti-oestrogenic effects on the breast. May also be
used for induction of ovulation in women with sub-fertility secondary to anovulation
Side-effects
Hot flushes (anti-oestrogenic effect), visual disturbance, amenorrhoea, irregular vaginal bleeding, GI disturbance,
hair loss, thromboembolism
Question 8 Which one of the above drugs has anti-oestrogenic activity in the breast?
Which one of the above drugs is an anti-oestrogen associated with an increased risk of
Question 9
endometrial cancer?
A Tranexamic acid B Tamoxifen

C Flutamide D Finasteride
E Spironolactone
Explanation
TAMOXIFEN
Action
and carcinoma
Clinical use
Side-effects
Question 10 Cyproterone acetate

A Can be used on its own as effective contraception B Has progestogenic activity
Is used to induce ovulation in women with
C Is an anti-oestrogen D
polycystic ovary syndrome
Is typically administered by intra-muscular
E
injection
Explanation
ANTI-ANDROGENS
Clinical use
• Treatment of androgenic symptoms in women with polycystic ovary syndrome (PCOS) especially hirsutism
• Anti-androgens may emasculate a male fetus therefore women must be informed of this risk and use effective
contraception while on treatment
Cyproterone acetate
• Progestogenic anti-androgen
• Used in combination with ethinyloestradiol as a combined oral contraceptive to treat acne and hirsutism
especially in women with Polycystic Ovary Syndrome (PCOS)
• Inhibits spermatogenesis (but is not a male contraceptive) & libido and reduces sebum production
Question 11 Which one of the above drugs does not have anti-androgenic activity?
A Norethisterone B Spironolactone
E Cimetidine
A(Correct answ er: A)
Explanation
ANTI-ANDROGENS
Clinical use
• Anti-androgens may emasculate a male fetus therefore women must be informed of this risk and use
effective contraception while on treatment
Cyproterone acetate
Spironolactone
• Aldosterone antagonist with anti-androgenic effects
• Used to treat hirsutism in women with PCOS
Finasteride
• 5-alpha reductase inhibitor
• Prevents the conversion of testosterone to the active metabolite dihydrotestosterone
Flutamide
• Androgen antagonist
• Used to treat hirsutism in PCOS
Cimetidine
• Displaces testosterone from its receptor
• Used to treat hirsutism in PCOS

Which one of the above anti-hypertensive drugs can cause lithium toxicity without an increase
Question 12
in lithium concentrations?
A Enalapril B Hydralazine
C Methyldopa D Labetalol
E Nifedipine
Explanation
METHYLDOPA
• Centrally acting anti-hypertensive agent
• Aromatic amino acid decarboxylase inhibitor. Converted to alpha-methylnoradrenaline in the CNS, where it stimulates
the central inhibitory alpha-adrenergic receptors, leading to a reduction in sympathetic tone, total peripheral
resistance, and blood pressure
• Reduction in plasma renin activity, as well as the inhibition of both central and peripheral noradrenalin and serotonine
production may also contribute to antihypertensive effect
• No direct effect on cardiac function and cardiac output and heart rate are unchanged
• Absorption from the gastrointestinal tract is variable but averages approximately 50%.
• Extensively metabolised by the liver. ~ 70% of the drug which is absorbed is excreted in the urine as methyldopa and
its mono-O-sulfate conjugate
• Crosses the placenta and is present in breast milk.
• Plasma half-life ~ 105 minutes
Contraindications
• Depression
Side-effects
• GI: dry mouth, stomatitis, hepatitis, jaundice, pancreatitis
• Nervous system: low mood / depression, drowsiness & reduced mental acuity, nightmares, mild psychosis,
parkinsonism, Bell’s palsy
• Musculo-skeletal: myalgia, SLE-like syndrome
• Drug fever
• Positive Coomb’s test in up to 20% of women and may affect blood cross-matching
Interactions
The following enhance hypotensive effects of methyldopa
• ACE inhibitors & other anti-hypertensive agents
• Alcohol
• General anaesthesia
Corticosteroids antagonise hypotensive effects of methyldopa
Lithium toxicity may occur without an increase in plasma lithium concentrations
Question 13 Magnesium sulphate
Causes direct inhibition of action potentials in Inhibits calcium efflux from muscle cells through
A B
smooth muscle dihydropyridine-sensitive calcium channels
C Is excreted by the kidneys at a rate which is D Is recommended for use in women with severe

inversely proportional to serum concentrations pre-eclampsia at least 24 hours before delivery
E Reduces the risk of eclampsia by 10-15%
Explanation
MAGNESIUM SULPHATE
• Used as an anticonvulsant in severe pre-eclampsia and eclampsia
• Magnesium is essential for the activity of many enzyme systems, neurochemical transmission and muscular
excitability
• Causes direct inhibition of action potentials in muscle cells. Excitation and contraction are uncoupled, which
decreases the frequency and force of contractions.
• 2+
Also inhibits Ca influx through dihydropyridine-sensitive calcium channels resulting in vascular smooth muscle
relaxation
• Excreted by the kidney at a rate proportional to the serum concentration and GFR
Indications
• Treatment of eclampsia
• Eclampsia prophylaxis in women with severe pre-eclampsia when decision has been made to deliver and in the
immediate post-partum period
• The MAGPIE trial showed that administration of magnesium sulphate to women with
• pre-eclampsia reduces the risk of an eclamptic seizure by 58% (95% CI 40–71%).The relative risk reduction was
similar regardless of the severity of pre-eclampsia.
• More women need to be treated when pre-eclampsia is not severe (NNT = 109) to prevent one seizure when
compared with severe pre-eclampsia (NNT = 63)
• If magnesium sulphate is given, it should be continued for 24 hours following delivery or 24 hours after the last
seizure, whichever is the later
• With i.v. administration, the onset of anticonvulsant action is immediate and lasts about 30 minutes.
• Following i.m. administration, the onset of action occurs after ~ 1 hour and persists for 3 to 4 hours.
Dose
• Loading dose of 4 g by iv infusion over 5–10 minutes
• Maintenance dose of 1 g/hour by iv infusion for 24h or 24h after the last seizure
• Recurrent seizures should be treated with either a further bolus of 2 g magnesium sulphate or an increase in the
infusion rate to 1.5 g or 2.0 g/hour
Question 14 Anti-D immunoglobulin
Should not be administered to Rhesus negative Should be administered at weekly intervals if a

A women who have given birth to a Rhesus B Rhesus negative woman is bleeding continuously
negative baby after 12 weeks gestation
Should be administered to Rhesus positive
C Cannot be administered intravenously D women in the event of a massive feto-maternal
haemorrhage
Should not be administered before 12 weeks
E
gestation
Explanation
Use of anti-D immunoglobulin

RHESUS BLOOD GROUP
• Six major antigens - C, D, E; c,d,e. However, there are at least 50 antigens in this blood group system
• An individual with the C antigen cannot have the c antigen; same for D & E antigens
• D antigen is most antigenic - individuals with D antigen are Rhesus positive. 16% of Caucasians are Rhesus negative
while 0.3% of Asians are Rhesus negative
• Immune response to Rhesus antigens is slow and peak antibody titres are attained 2-4 months after exposure.
Transfusion reaction in an unsensitized individual is therefore delayed
• D antigen causes severe Rhesus disease. C & E antigens can cause mild fetal haemolysis. Usually the first
pregnancy is not affected, but may be if the mother had received incompatible blood products
• The offspring of two Rh negative individuals must be Rh negative. The offspring of a Rh negative and a Rh positive
individual may be Rh negative as the Rh positive parent may be heterozygous
Mechanism of action of anti-D immunoglobulin
• Administered anti-D immunoglobulin binds to and removed Rh +ve fetal red cells before the maternal immune system
encounters these cells and becomes sensitized.
Recommended route / dose
• im, some available iv; s/c if bleeding disorder
Sensitizing events
• At least 250 IU before 20 weeks
• At least 500 IU after 20 weeks + Kleihauer test
• Administer within 72h of event
• 500IU covers 4ml fetal red cells
• 100-125 IU per additional ml of fetal red cells
Post-partum
• 500 IU within 72h of birth if baby Rh +ve
• Need a robust system to identify Rh +ve babies and ensure treatment is not missed or delayed
Where bleeding continues intermittently after 12 weeks gestation anti D should be given at 6 weekly intervals
Question 15 Which one is not an anti-cholinergic drug?
A Tolterodine B Solifenacin
C Trospium chloride D Duloxetine
E Flavoxate
Explanation
Drugs acting on the bladder
Anti-cholinergic agents
Oxybutynin, Tolterodine, Propiverine, Solifenacin, darifenacin, fesoterodine, flavoxate, trospium chloride
Reduce involuntary bladder contractions with direct relaxant effect on the detrusor
Result in improvement in 57-71% of women with detrusor over-activity
Have significant placebo effect.
Side-effects, especially dry mouth appear to be less common with newer agents like tolterodine and solifenacin.
Oxybutynin - Side-effects include:
• Dry mouth (88%)

• Nausea, constipation, diarrhoea and abdominal discomfort
• Blurred vision
• Voiding difficulties
• Headache, dizziness, drowsiness, restlessness and disorientation
• Rash, dry skin, photosensitivity
• Arrhythmia
• Angioedema

May precipitate angle closure glaucoma
Modified release preparation of oxybutynin has fewer side-effects and a trans-dermal patch is also available
The efficacy and side-effects of tolterodine are similar to those of modified-release oxybutynin
Flavoxate is less effective but has fewer side-effects
Contra-indications
• Myasthenia gravis
• Urinary retention / bladder outflow obstruction
• Severe ulcerative colitis, GI obstruction or intestinal atony
Question 16 Desmopressin
Is a shorter-acting analogue of anti-diuretic

A B Has vaso-constrictor effects
hormone
Is effective treatment for urodynamic stress Is contra-indicated in women who are treated with
C D
incontinence diuretics
E Is a recognised cause of hypernatraemia
Explanation
Anti-diuretic hormone (Desmopressin, DDAVP)
• Desmopressin is a longer-acting analogue of ADH (vasopressin)
• Desmopressin does not have vaso-constrictor effects
• Administered by mouth, sub-lingual or nasal spray
• Effective in treatment of nocturia and nocturnal enuresis
• Contraindicated in cardiac disease and women on diuretics
• Patients should avoid fluid overload (including during swimming) and treatment should be discontinued during
periods of vomiting or diarrhoea
• Side-effects include fluid retention with hyponatraemia, epistaxis, nasal congestion and rhinitis with nasal spray
Question 17 Which one of the above statements regarding dimethyl sulfoxide is true?
Results in symptomatic improvement in women

A Is administered directly into the bladder B
with stress incontinence
C Is a 5HT re-uptake inhibitor D Is a nor-adrenaline re-uptake inhibitor
E Has anti-cholinergic effects on the bladder
Explanation
Dimethyl Sulfoxide
• Used for symptomatic treatment of interstitial cystitis

• 50ml of 50% solution instilled into the bladder for 15 minutes then the bladder is emptied
• Treatment repeated at intervals of 2 weeks
• Associated with bladder spasm and hypersensitivity reactions
• Long-term use requires hepatic, renal and ophthalmic assessment every 6 months

Question 18 A third generation progestogen
A Norethisterone B Finesteride
C Drospirenone D Yasmin
E Desogestrel
Explanation
COMBINED ORAL CONTRACEPTIVE PILL
DOSE
Oestrogen:
Contain 35, 30 or 20mcg (Loestrin 20 / Mercilon / Femodette) ethinyl oestradiol (pills containing 50mcg ethinyl
oestradiol are rarely used)
Progestogen:
2nd generation
Norethisterone 1mg
Levonorgestrel 150mcg
3rd generation
Desogestrel 150mcg
Gestodene 150mcg
Norgestimate 250mcg
Spironolactone derivative
Drospirenone 3mg
Progestogen used in the combined oral contraceptive pill and associated with a higher risk of
Question 19
A Medroxyprogesterone acetate B Norethisterone

C Levonorgestrel D Gestodene
E Drospirenone
Explanation
Risk of VTE as follows:
1) Healthy woman not taking COCP - 5 / 100,000
2) Second generation COCP user - 15 / 100,000
3) Third generation COCP user (desogestrel or gestodene) - 25 / 100,000
4) Pregnancy - 60 / 100,000

Contra-indication (UKMEC 3 or 4) to use of depo-medroxyprogesterone acetate for
Question 20
contraception
A Personal history of DVT B BMI of 35 kg/m2

C BMI 45 kg/m2 D Severe thrombocytopaenia
E Age 37 years and smoking 3-5 cigarettes per day
Explanation
Progestogen-only Injectables: UKMEC 3 – Risks outweigh benefits
Cardiovascular
• Multiple risk factors for cardiovascular disease (such as age, smoking, diabetes, hypertension, obesity)
• Vascular disease
• Current / history of ischaemic heart disease
• Stroke
Malignancy
• Unexplained vaginal bleeding before investigation
• Past history of breast cancer with no evidence of recurrence for 5 years (current breast cancer = UKMEC 4)
Endocrine
• Diabetes mellitus with nephropathy, neuropathy or retinopathy
GI Disorders
• Severe decompensated cirrhosis, hepatocellular adenoma and hepatoma
Rheumatological
• SLE with positive or unknown anti-phospholipid antibodies or severe thrombocytopaenia (im injection). (SLE on its
own or on immuno-suppressive therapy = UKMEC 2)
Question 21 Contra-indication (UKMEC 3 or 4) to use of progestogen-only implants for contraception
A Family history of myocardial infarction B Personal history of DVT

Treated breast cancer with no recurrence after 10
C Gestational diabetes in previous pregnancy D
years
E BMI 45 kg/m2
Explanation
Progestogen-only Implants: UKMEC 3 – Risks outweigh benefits
Cardiovascular
• Current / history of ischaemic heart disease (Continuation). UKMEC 2 for initiation
• Stroke (Continuation). UKMEC 2 for initiation
Malignancy
GI Disorders
Rheumatological
• SLE with positive or unknown anti-phospholipid antibodies (SLE on its own or on immuno-suppressive therapy or
severe thrombocytopaenia = UKMEC 2)

Question 22 Which one is licensed for post-coital contraception in the UK?
A Gestodene B Desogestrel
C Norgestimate D Drospirenone
E Copper intra-uterine contraceptive device
Explanation
Post-coital contraception
• 750mcg levonorgestrel x 2 doses 12h apart effective in preventing pregnancy and has significantly fewer side-effects
- nausea / vomiting / breast tenderness.
• Single dose (1.5 mg) administration seems to have similar effectiveness as the standard 12 hours apart split-dose
(750 mcg twice) of levonorgestrel
• Copper IUCD effective post-coital contraceptive - may be used up to 5 days after unprotected intercourse or after the
most probable day of ovulation - failure rate < 0.1%
A healthy 23 year old woman wishes to use the combined oral contraceptive pill as soon as
Question 23
possible. She has a regular 28 day cycle and her LMP was 3 days ago.
Start immediately, additional contraception for 7

A Start immediately & no additional contraception B
days
Start immediately, additional contraception for Start immediately, additional contraception for
C D
48h 24h
Start immediately, additional contraception for
E
72h
Explanation
When to start COCP
Ideally within first 5 days of menstrual cycle. No need for additional contraception
Need additional contraception for 7 days if started at other times. Exclude pregnancy
Start on day 21 postpartum if NOT breastfeeding
Start after 6 months if fully breastfeeding
Start within 5 days if post abortion without need for additional contraception. Otherwise, use barrier methods or
abstinence for 7 days.
When to start Progestogen-only pill
Start on day 1 of the cycle and take 1 pill everyday.
Can be started up to and including day 5 of menstrual cycle without need for additional contraception. If started
after day 5 and woman is not pregnant, needs additional contraception for 48 hours.
Can be started up to and including day 21 post partum without need for additional contraceptive cover
Can be started within 5 days of termination of pregnancy or miscarriage (< 24wks gestation)
Can be continued up to age 55 yrs if no contraindications
A healthy 33 year old woman wishes to start using the intra-uterine contraceptive device as
soon as possible. Following counselling, the levonorgestrel releasing device is recommended.
Question 24
Her LMP was 7 days ago and she has a regular 28 day cycle. She has been using condoms for
contraception.
A Start immediately, additional contraception for 5 B Start immediately, additional contraception for 7

days days
C Start immediately & no additional contraception D
24h
E
48h
Explanation
When to start Levonorgestrel Intrauterine system (Mirena)
Can be inserted anytime within the 1st 5 days of menstrual cycle without need for additional contraceptive cover.
Can be started at any other time provided the woman is not pregnant. Use condoms or abstinence for 7 days.
Postpartum – insert from 4 weeks postpartum
Post abortion / miscarriage – insert within 48 hrs or delay until 4 weeks post abortion.
When to start Copper intrauterine contraception
Can be inserted at any time provided the woman is not pregnant. A Cu-IUD is effective immediately.
Post abortion / miscarriage – insert within 48 hrs or delay until 4 weeks post abortion
Question 25 Beta agonists used for tocolysis are associated with
A significant reduction in the risk of delivery A significant reduction in the risk of delivery within
A B
before 37 weeks gestation 48 hours of starting treatment
C A significant improvement in perinatal outcome D A significant reduction in perinatal mortality
E A significant increase in maternal mortality
Explanation
BETA-AGONISTS
• Now less commonly used because of side-effects and availability of safer alternatives
• Reduce sensitivity to, and total intracellular calcium concentrations causing myometrial relaxation
• Recommended for use between 20-35 completed weeks including women with ruptured membranes
• Use only if delay required to administer corticosteroids or enable in-utero transfer
• Women with known cardiac disease should not be given beta agonists
• Caution in multiple pregnancy (increased risk of pulmonary oedema) and diabetes mellitus especially when
corticosteroids used
• Cross placenta and cause fetal tachycardia, hyperglycaemia and hyperinsulinaemia
• Maximum recommended dose is 350 micrograms/min - use minimum dose necessary to inhibit uterine contractions
and maintain maternal pulse <140bpm. Starting dose 50 micrograms/min
• 5% dextrose recommended as infusing solution
Recommended monitoring:
1) Maternal pulse every 15 min

2) BP every 15 min initially
3) Blood glucose 4 hourly
4) Fluid in-put out-put chart
5) U & E every 24h
6) Auscultation of lung fields every 4h
Side-effects
Commonest - palpitations, tremor, nausea, vomiting, headache, restlessness, tachycardia (dose-related).

Heart rate should not exceed 140bpm because of associated risk of pulmonary oedema. Associated with
hypotension.
Rare side-effects include pulmonary oedema (secondary to anti-diuretic effect and excessive fluid in-put), myocardial
ischaemia, hyperglycaemia and hyperinsulinaemia.
Pulse pressure is increased (increased cardiac out-put + peripheral vasodilatation)
Which one is a recognised contraindication to the use of oxytocin for augmentation or induction
Question 26
of labour?
A Major placenta previa B Suspected chorioamnionitis

C Intra-uterine fetal death D Severe pre-eclampsia
E Suspected placental abruption
Explanation
OXYTOCIN
Contraindications
• Fetal distress
• Severe hypertensive disease / pre-eclampsia
• Conditions where vaginal delivery is contraindicated
• Hypertonic uterine contractions
Side-effects
• Nausea and vomiting (less common than ergometrine)
• Uterine hyper-stimulation
• Fetal distress
• Uterine rupture
• Water intoxication
• Placental abruption
• Amniotic fluid embolism
• Disseminated intravascular coagulation
Question 27 Which one is a recognised side-effect of carbetocin?
A Hypertension B Nausea & vomiting

C Bradycardia D Diarrhoea
E Rigors
Explanation
Carbetocin
• Synthetic analogue of oxytocin
• Uterine stimulant. Carbetocin has a longer duration of action compared with oxytocin
• Should be stored under refrigeration at 2 to 8°C
Indications
• Prevention of postpartum haemorrhage following caesarean section.
Mechanism of action
• Binds to oxytocin receptors on uterine smooth muscle, resulting in rhythmic contractions of the uterus, increased
frequency of existing contractions, and increased uterine tone.

• Onset of action is within 2 minutes of intramuscular or intravenous administration and effects last for up to 1 hour
Contraindications
• Pre-eclampsia, eclampsia, epilepsy, hepatic & renal impairement. Avoid if severe cardiovascular disease
Side-effects
• Nausea, vomiting, abdominal pain, metallic taste, flushing, hypotension, tachycardia
Question 28 Which one is not a recognised effect of active management of the third stage of labour?
A Increased risk of raised blood pressure B Increased need for blood transfusion
C A shortening of the length of the third stage D Reduced risk of severe post-partum haemorrhage
E Increased risk of nausea and vomiting
Explanation
Third stage of labour: Active Vs Expectant management
• Active management consists of
• Administration of uterotonic agent (oxytocin)
• Delivery of the placenta by controlled cord traction
• Whether early clamping of the cord is part of active management of the third stage is controversial
Compared with expectant management, active management is associated with

• Shorter third stage (mean difference, ~10 minutes)
• Reduced risk of postpartum hemorrhage (NNT= 12)
• Reduced risk of severe postpartum hemorrhage (NNT = 57)
• Reduced risk of anaemia (NNT = 27)
• Reduced need for blood transfusion (NNT = 65)
• Reduced need for additional uterotonic medications (NNT = 7)
• Increased risk of maternal nausea (number needed to harm [NNH] = 15)
• Increased risk of vomiting (NNH = 19)
• Increased risk of raised blood pressure (NNH = 99)
• No difference in risk of retained placenta
• No difference in neonatal outcomes
With respect to the prevention of post-partum haemorrhage (PPH) following vaginal birth at
Question 29
term
Use of ergometrine is associated with reduced Use of ergometrine is associated with reduced
A rate of PPH over 1000 ml compared to use of B rate of blood transfusion compared to use of
oxytocin oxytocin
Use of ergometrine is associated with reduced
Use of ergometrine is associated with increased
C need for additional uterotonic medications D
risk of vomiting compared to use of oxytocin
compared to use of oxytocin
Use of oxytocin is associated with an increased
E risk of hypertension compared to use of
ergometrin

Explanation
Oxytocin Vs Ergometrine
Compared to oxytocin, use of ergometrine in the active management of the third stage of labour resulted in
• No difference in post-partum haemorrhage over 1000 ml
• No difference in need for blood transfusion
• No difference in need for additional uterotonic medications
• Significant increase in the incidence of side-effects especially vomiting and raised blood pressure
A 34 year old woman has a dinoprostone vaginal delivery system (PROPESS) inserted for
Question 30
induction of labour. Which one of the above statements is true?
An interval of at least 6 hours is recommended

The woman should remain recumbent for 20-30
A B between removal of the system and use of
minutes after insertion
oxytocin
If the woman is not in labour after 6 hours, a The delivery system should not be inserted if the
C D
second system should be inserted cervical score is 8 or more
If the woman is not in labour after 24h, a second
E
system should be inserted
Explanation
Dinoprostone vaginal delivery system
Dose
• One vaginal delivery system to be placed high into the posterior vaginal fornix
• Use water soluble lubricant
• Ensure sufficient tape outside the vagina to allow removal if needed
• The woman should be recumbent for 20-30 minutes after insertion.
• If labour or sufficient cervical ripening does not occur after 24 hours, the delivery system should be removed. The
woman’s condition should be reviewed and options for further management discussed
• An interval of at least 30 minutes is recommended between removal of the delivery system and use of oxytocin

E Desogestrel
Explanation
DOSE
Oestrogen:
Progestogen:
2nd generation
Norethisterone 1mg
3rd generation
Desogestrel 150mcg
Gestodene 150mcg
Norgestimate 250mcg
Drospirenone 3mg
Question 2 A second generation progestogen
A Norgestimate B Medroxyprogesterone acetate

C 17-hydroxyprogesterone D Levonorgestrel
E Gestodene
Explanation
DOSE
Oestrogen:
Progestogen:

2nd generation
Norethisterone 1mg
3rd generation
Desogestrel 150mcg
Gestodene 150mcg
Norgestimate 250mcg
Drospirenone 3mg
Question 3 The oestrogen used in combined oral contraceptive pills
A Oestradiol B Oestrone
C Oestriol D Ethinyl-oestradiol
E Gestodene
Explanation
OMBINED ORAL CONTRACEPTIVE PILL
DOSE
Oestrogen:
Progestogen:
2nd generation
Norethisterone 1mg
3rd generation
Desogestrel 150mcg
Gestodene 150mcg
Norgestimate 250mcg
Drospirenone 3mg
Risk of venous thrombo-embolism in a healthy woman who is not taking hormonal

Question 4
contraception
Risk ofvenous thrombo-embolism in a healthy woman who is taking combined oral
Question 5
contraception containing levonorgestrel
A 1 in 100,000 B 2.5 in 100,000

C 5 in 100,000 D 15 in 100,000

E 20 in 100,000
Explanation
4) Pregnancy - 60 / 100,000
Question 6 Absolute contra-indication (UKMEC 4) to use of the combined oral contraceptive pill
12 weeks after vaginal delivery and not

A Age 37 years and smoking 3-5 cigarettes per day B
breastfeeding
12 weeks after caesarean section and not Age 20 years with a history of focal migraine at
C D
breastfeeding the age of 15 years
E Recent molar pregnancy
Explanation
CONTRA-INDICATIONS TO COCP
UKMEC 4 – unacceptable health risks or absolute contraindications
Personal
• Age over 35 years and smoking ≥15 cigarettes / day
Cardiovascular
• Multiple risk factors for arterial cardiovascular risk e.g. older age, diabetes, hypertension, smoking.
• Hypertension: Systolic BP > 160mmHg or diastolic > 94 mmHg
• VTE risk: Personal history of VTE, major surgery with prolonged immobilisation, thrombophilia
• Current or history of ischaemic heart disease, stroke or peripheral vascular disease
Neurological
• Migraines with aura at any age
Endocrine
• Diabetes mellitus: Retinopathy, nephropathy, neuropathy or diabetes > 20 yrs duration (otherwise IDDM and
NIDDM are UKMEC 2).
Malignancy
• Current breast cancer or other oestrogen / progesterone-sensitive tumour
GI Disorders
• Active viral hepatitis and severe (de-compensated cirrhosis). Hepatocellular adenoma & hepatoma
Rheumatological
• SLE with positive or unknown anti-phospholipid antibodies (SLE on its own or with severe thrombocytopaenia or
use of immuno-suppressive therapy are UKMEC 2)
• Raynaud’s disease with lupus anticoagulant (Primary Raynaud,s disease = UKMEC 1 and Raynaud’s disease
without lupus anticoagulant = UKMEC 2)
Pregnancy
• Within 6 weeks post-partum and breast-feeding

• Note that gestational trophoblastic disease with decreasing or undetectable HCG, persistently elevated HCG or
malignant disease are all UKMEC 1 (UNRESTRICTED USE) for COCP
A 2 tablets of progestogen-only pill B Levonorgestrel

C Levonorgestrel-releasing intra-uterine device D Gestodene
E Desogestrel
Explanation
A healthy 34 year old woman wishes to start the progestogen-only oral contraceptive pill as
Question 8
soon as possible. She has a regular 28 day cycle and her LMP was 10 days ago

days
C D
48h 24h
E
72h
Explanation
When to start COCP
A healthy 23 year old woman wishes to discuss contraception after a vaginal delivery at term.
Question 9
She is breastfeeding and wishes to use the progestogen-only oral contraceptive pill

A B Start 21 days after delivery
days
C Start after 6 weeks D Start 6 months after delivery
Start 21 days after delivery with additional
E
contraception for 7 days
Explanation
A healthy 35 year old woman is reviewed in the gynaecology clinic 8 days after medical
Question 10 termination of pregnancy. She wishes to use the progestogen-only implant as soon as possible
for contraception

A B Start immediately & no additional contraception
days
C D
24h 48h
E
72h
Explanation
When to start progestogen only implants & injectables
Ideally in the 1st 5 days of cycle. No additional contraception needed.
Can be inserted at any other time provided woman is not pregnant. Use barrier methods or abstinence for 7 days
Can be started up to and including day 21 post partum without need for additional contraceptive cover. If started
after day 21, use barrier methods or abstinence for 7 days.
Can be started within 5 days of termination of pregnancy or miscarriage (< 24wks gestation) without need for
additional contraception. If after 5 days, advise barrier methods or abstinence for 7 days.

Question 1 Which one of the above statements regarding Tranexamic acid is true?

A Is an anti-androgenic agent B
Is ineffective in reducing heavy menstrual Is ineffective in reducing heavy menstrual
C D
bleeding associated with the copper IUCD bleeding in women with a bleeding disorder
Is effective in reducing heavy menstrual bleeding
E
in women with fibroids
Explanation
Tranexamic acid
Contraindications
Side effects
Question 2 Which one of the above is a recognised contra-indication to treatment with danazol?
A Family history of breast cancer B Active liver disease

C Severe asthma D Heavy menstrual bleeding
E Dysmenorrhoea
Explanation
Danazol
Contraindications
• Breastfeeding

Question 3
loss?

E GnRH analogue
Explanation
GnRH analogues
FSH and LH release
Indications
Administration
Side-effects
• Headache
• Ovarian cysts

weeks
Explanation
GnRH analogues
FSH and LH release

Indications
Administration
Side-effects
• Headache
• Ovarian cysts

menopausal uterus
Explanation
TAMOXIFEN
Action
and carcinoma
Clinical use
Side-effects
Question 6
endometrial cancer?

E Spironolactone
Explanation
TAMOXIFEN
Action
and carcinoma
Clinical use
Side-effects
Which one of the above drugs is used to prevent breast cancer recurrence and is not
Question 7
associated with an increased risk of endometrial cancer?
A Flutamide B Finasteride
C Spironolactone D Gestrinone
E Raloxifen
Explanation
RALOXIFEN
This is the archetypal Selective oEstrogen Receptor Modulator (SERM) developed to maximise the anti-
oestrogenic effects on specific tissues without the potentially damaging oestrogenic effects on other tissues
Clinical use
Used in the treatment and prevention of post-menopausal osteoporosis
Oestrogen-antagonist in breast therefore not associated with increased risk of breast cancer
Oestrogen antagonist / neutral on the uterus – therefore not associated with increased risk of endometrial cancer
(unlike tamoxifen).
Does not relieve hot flushes
Side-effects
Hot flushes, leg cramps, thromboembolism, GI upset and flu-like symptoms
Which anti-hypertensive drug is a recognised cause of profound hypotension and fetal

Question 8
distress?
A Captopril B Hydralazine
C Enalapril D Labetalol
E Methyldopa

Explanation
HYDRALAZINE
• Vasodilator (arterioles more than venules) by direct effect on vascular smooth muscle and reduces cardiac after-load
• Also has antioxidant effects, reducing superoxide formation and enhancing the vasodilator effects of nitric oxide
• Excessive superoxide counteracts NO-induced vasodilation. It is commonly used in the condition of pregnancy called
preeclampsia
• Hydralazine-induced decrease in blood pressure is accompanied by increased heart rate, cardiac output, and stroke
volume secondary to reflex response to decreased peripheral resistance
• No direct effect on cardiac function
• Increases renin activity in plasma leading to increased production of angiotensin II and sodium reabsorption with fluid
retention.
• Tolerance to the antihypertensive effect of the drug may therefore develops with long-term use especially if a diuretic
is not administered concurrently
• Rapidly and extensively absorbed from the gut and undergoes extensive first-pass metabolism by genetic
polymorphic acetylation. Hepatic metabolites excreted in urine
• Oral bioavailability is therefore variable and dependent on acetylator phenotype
• ~87% protein-bound. Half life 3-7h
Indications
• Treatment of severe pregnancy induced hypertension which has not responded to other agents (iv therapy)
• Can result in profound hypotension and fetal distress. Pre-loading with iv fluids therefore used prior to treatment to
minimise the risk of profound hypotension
Interactions
• Corticosteroids antagonise hypotensive effects of hydralazine
• Hypotensive effects enhanced by other anti-hypertensives
Contraindications
• SLE
• Severe tachycardia
Side-effects
• Tachycardia, flushing, palpitations, hypotension
• SLE-like syndrome with long-term therapy
Risk of side-effects of this drug are increased in women also taking contraceptives containing
Question 9
drospirenone
A Hydralazine B Methyldopa
C Labetalol D Amlodipine
E Captopril
Explanation
CAPTOPRIL
• Competitive inhibitor of angiotensin-converting enzyme (ACE)
• ACE converts angiotensin I (ATI) to angiotensin II (ATII). Captopril’s affinity for ACE is approximately 30,000 times
greater than that of ATI
• ATII regulates blood pressure and is a key component of the renin-angiotensin-aldosterone system
• Causes an increase in plasma renin activity due to a loss of feedback inhibition mediated by ATII on the release of
renin and/or stimulation of reflex mechanisms via baroreceptors
• One of the few ACE inhibitors that is not a prodrug
• 60-75% absorbed in fasting individuals; food decreases absorption by 25-40%
• Metabolised by the liver

Indications
• Post-partum treatment of hypertension in women with chronic hypertension
Contraindications
• Pregnancy
• Should be used with caution in renal impairment – risk of hyperkalaemia
Side-effects
• Hypotension
• Renal impairment
• Persistent dry cough, sinusitis, rhinitis and sore throat
• Angioedema
• Hyperkalaemia
• Derangement of liver function
Interactions
• Drospirenone - Increased risk of hyperkalemia
• Lithium - Increased serum levels of lithium
• Potassium - Increased risk of hyperkalemia
• Spironolactone - Increased risk of hyperkalemia
Question 10 Angiotensin converting enzyme inhibitor
E Amlodipine
Explanation
CAPTOPRIL
Indications
Contraindications
• Pregnancy
Side-effects
• Hypotension
• Angioedema
• Hyperkalaemia
Interactions

Question 11 Concentration of magnesium associated with cardiac arrest
A 2.0 – 4.0 mM B 4.0 – 5.0 mM

C 5.0 – 7.0 mM D > 7.5 mM
E > 12 mM
Explanation
Monitoring of MgSO4 therapy
Clinical
• Hourly tendon reflexes. Use arm reflexes if regional anaesthesia
• Renal function
• Hourly urine outputCardio-respiratory
• ECG during and for 1 hour after loading dose
• SO2 continuously
Magnesium Levels & toxicity
Magnesium levels should be checked every 6-12 hours. Close monitoring is required in women with < 100 ml urine
output in 4h, serum urea > 10 mM, and those with known renal impairment
0.8 – 1.0 mM: Normal plasma levels
2 – 4 mM: Therapeutic range
2.5 – 5.0 mM: ECG changes with prolonged P-Q interval and widened QRS complexes
4 - 5 mM: Diminished tendon reflexes, muscle weakness, diplopia, slurred speech.
Action: Stop infusion, check Mg levels
>5 mM: Loss of tendon reflexes
> 7.5 mM: Sino-atrial and atrio-ventricular block. Respiratory paralysis and CNS depression
>12 mM: Cardiac arrest

hormone
C D
Explanation

E Desogestrel
Explanation
DOSE
Oestrogen:
Progestogen:
2nd generation
Norethisterone 1mg
3rd generation
Desogestrel 150mcg
Gestodene 150mcg
Norgestimate 250mcg
Drospirenone 3mg
Question 14

E Drospirenone
Explanation

4) Pregnancy - 60 / 100,000
Question 15 Risk ofvenous thrombo-embolism in a healthy pregnant woman
A 5 in 100,000 B 15 in 100,000
C 20 in 100,000 D 25 in 100,000
E 60 in 100,000
Explanation
close
4) Pregnancy - 60 / 100,000
Risk ofvenous thrombo-embolism in a healthy woman who is taking combined oral

Question 16
contraception containing levonorgestrel
A 1 in 100,000 B 2.5 in 100,000

C 5 in 100,000 D 15 in 100,000
E 20 in 100,000
Explanation
4) Pregnancy - 60 / 100,000

Question 17
contraception

Explanation
Cardiovascular
• Stroke
Malignancy
Endocrine
GI Disorders
Rheumatological
Question 18 Drug that is typically used to treat uterine hyperstimulation following induction of labour
A Dinoprostone B Ritodrine
C Atosiban D Terbutaline
E None of the above
Explanation
Atosiban
• Competitive oxytocin / vasopressin antagonist
• Associated with significant increase in the number of women remaining undelivered at 24, 48h and 7 days after
commencing treatment compared to placebo.
• Infant mortality was not significantly different at >28 weeks gestation but was significantly INCREASED in the
atosiban group at <28 weeks gestation
• Similar efficacy to beta agonists but with fewer cardiovascular side-effects
Terbutaline Sulphate
• Recommended for use in the treatment of uterine hyper-stimulation associated with induction of labour
• Also used to reduce uterine tone prior to external cephalic version. Associated with improved success rates
especially in primigravidae
• May be used to reduce uterine activity if ‘fetal distress’ is evident while preparations are being made for delivery
• Administered by sub-cutaneous injection 250 micrograms
Ritodrine
• Now less commonly used because of cardiovascular side-effects and availability of safer alternatives

Question 19 Which one of the above statements regarding atosiban is true?
A Is an oxytocin agonist B Is a vasopressin antagonist

Is administered by intravenous loading dose
C Should not be used if cervical dilatation is evident D
followed by an oral maintenance dose
Should be administered for 10 days or until
E
delivery
Explanation
OXYTOCIN ANTAGONISTS
Atosiban - competitive oxytocin / vasopressin antagonist

Associated with significant increase in the number of women remaining undelivered at 24, 48h and 7 days after
Infant mortality was not significantly different at >28 weeks gestation but was significantly INCREASED in the
Similar efficacy to beta agonists but with fewer cardiovascular side-effects
Much more expensive compared to ritodrine or nifedipine
Contraindications
Eclampsia & severe pre-eclampsia
Intra-uterine infection
Fetal death
Antepartum haemorrhage
Pre-term premature rupture of the membranes
Side-effects: nausea, vomiting, tachycardia, hypotension, headache, hyperglycaemia, hot flushes, injection site
reaction
Administration: intra-venous
Loading dose of 6.75mg over 1 minute then
18mg/hour for 3 hours then
6mg/hour for maximum total treatment duration of 48 hours
Question 20 Therapeutic oxytocin
Produces a uterine response after 5-10 minutes

A Has a plasma half life of ~ 30 seconds B
of intramuscular injection
Produces a uterine response within 2 minutes of
C D Is mostly excreted in the urine unchanged
intravenous injection
Following intravenous injection of 5 IU, the uterine
E
response lasts for up to 12 hours
Explanation
Oxytocin
• Nonapeptide found in posterior pituitary gland. Therapeutic oxytocin is synthesised chemically

• Differs from anti-diuretic hormone in 2 of the 9 amino acids. Has weak anti-diuretic properties which may become
relevant if large doses are administered
• The biologically active form of oxytocin is the oxidised molecule which is an octapeptide
• Stimulates uterine smooth muscle contraction by increasing the intracellular Ca2+
• Has specific receptors (G-protein coupled receptor) in the myometrium and the receptor concentration increases
during pregnancy, reaching a peak in early labour at term
• The uterine response to a given dose of oxytocin is variable and depends on the sensitivity of the uterus, which is
determined by the oxytocin receptor concentration
• Plasma half-life is 1 to 6 minutes which is decreased in late pregnancy and during lactation. Metabolised by the
kidney and liver. Only small amounts are excreted in urine unchanged.
• Following intravenous administration, uterine response occurs almost immediately and subsides within 1 hour
• Following intramuscular injection, uterine response occurs within 3 to 5 minutes and persists for 2 to 3 hours
Question 21 Oxytocin used in the management of labour
A Is extracted from the posterior pituitary gland B Has anti-diuretic effects

Acts by reducing intracellular free Ca2+
C D Acts through a phospholipase-A coupled receptor
concentrations in the myometrium
Produces a uterine response which is directly
E
dependent on the dose administered
Explanation
Oxytocin
• Nonapeptide found in posterior pituitary gland. Therapeutic oxytocin is synthesised chemically
• Differs from anti-diuretic hormone in 2 of the 9 amino acids. Has weak anti-diuretic properties which may become
relevant if large doses are administered
• The biologically active form of oxytocin is the oxidised molecule which is an octapeptide
• Stimulates uterine smooth muscle contraction by increasing the intracellular Ca2+
• Has specific receptors (G-protein coupled receptor) in the myometrium and the receptor concentration increases
during pregnancy, reaching a peak in early labour at term
• The uterine response to a given dose of oxytocin is variable and depends on the sensitivity of the uterus, which is
determined by the oxytocin receptor concentration
• Plasma half-life is 1 to 6 minutes which is decreased in late pregnancy and during lactation. Metabolised by the
kidney and liver. Only small amounts are excreted in urine unchanged.
• Following intravenous administration, uterine response occurs almost immediately and subsides within 1 hour
• Following intramuscular injection, uterine response occurs within 3 to 5 minutes and persists for 2 to 3 hours.
Indications
Induction and augmentation of labour
• Administer by intravenous infusion with dose titrated to uterine contractions and fetal heart rate assessment
• The infusion should be made up using normal saline
• Continuous electronic fetal heart rate monitoring should be used with hourly systematic assessment using the DR C
BRAVADO mnemonic
• Aim to achieve no more than 4-5 contractions every 10 minutes. Frequency of uterine contractions should be
assessed and documented every 15 minutes
• Reduce dose if contracting more than 5 in 10 minutes.
• Consider reducing dose if CTG is suspicious or pathological. Infusion should be stopped in the event of fetal
bradycardia
• Starting dose 1-4 mIU / min. Maximum dose 32 mIU / min
• Dose should not be increased more frequently than every 30 minutes
• Should not be started within 6 hours of vaginal PGE2 gel or tablets

• Should be used cautiously in women with a previous caesarean section
• Clinical assessment should be undertaken by an obstetrician before oxytocin is used to augment spontaneous labour
in a multiparous woman. An individualised plan should be documented indicating the timing of the next vaginal
examination
Which drug is recommended for use in induction of labour at term in women with an
Question 22
unfavourable cervix?
A Vaginal gemeprost 1mg B Vaginal prostaglandin E2 gel 2mg

C Oral prostaglandin E2 D Intramuscular carboprost
E Vaginal carboprost
Explanation
Dinoprostone (prostaglandin E2)
• Naturally occurring prostaglandin
• Available as tablets, gels and sustained release delivery systems
• Rapidly metabolised locally within tissues. Any drug reaching the systemic circulation is metabolised by the lungs and
liver. The products of dinoprostone metabolism are eliminated by the kidneys
• Half life less than 5 minutes
• Administered intravaginally
• Stimulates myometrial contractions similar to those of normal labour
• Mechanism of direct myometrial stimulation is unknown but are likely to be through alteration of intracellular calcium
concentrations
• Also has local cervical effects including softening, effacement, and dilation (ripening of the cervix) by modulating
collagen degradation caused by secretion of the enzyme collagenase
Indications
• Induction of labour at term
Gemeprost
• 16, 16-dimethyl-trans-delta2 PGE1 methyl ester
• Prostaglandin E1 analogue
• Stimulates uterine contractions and causes ripening of the cervix within 3 hours
of vaginal administration
• Decreases placental and uterine blood flow secondary to uterine stimulation
• Effective cervical dilator in the first and second trimester
• Plasma levels are very low following vaginal administration
• 12 - 28% of the vaginal dose is eventually absorbed into the circulation, and 50%
of this is excreted in the urine
• The unabsorbed dose is largely washed out in the urine or found in pads used to
absorb vaginal blood loss
• Store in freezer below -10 C. Allow to warm at room temperature for 30 minutes
before administration
Indications
• Cervical ripening prior to first trimester surgical termination of pregnancy. 1mg
into the posterior vaginal fornix 3h before surgery

• Second trimester termination of pregnancy. 1mg into the posterior vaginal fornix
every 3h for a maximum of 5 doses. Second course may begin 24h after start of
treatment. If second course fails, pregnancy should be terminated by another
means
• Management of intra-uterine fetal death in the second trimester. 1mg into the
posterior vaginal fornix every 3h for a maximum of 5 doses.
Question 23 Which one is not a recognised complication of oxytocin used to induce or augment labour?
A Uterine hyperstimulation B Placental abruption

C Water intoxication D Amniotic fluid embolism
E Endometritis
Explanation
OXYTOCIN
Contraindications
• Fetal distress
• Severe hypertensive disease / pre-eclampsia
• Conditions where vaginal delivery is contraindicated
• Hypertonic uterine contractions
Side-effects
• Nausea and vomiting (less common than ergometrine)
• Uterine hyper-stimulation
• Fetal distress
• Uterine rupture
• Water intoxication
• Placental abruption
• Amniotic fluid embolism
• Disseminated intravascular coagulation
Question 24 Ergometrine maleate
A Is an oxytocin analogue B Stimulates contraction of the cervix

Causes hypotension if administered by rapid
C Increases uterine blood flow D
E Binds to oxytocin receptors in the uterus
Explanation
Ergometrine Maleate
• An amine ergot alkaloid.
• Stimulates contractions of uterine and vascular smooth muscle
• Increases the amplitude and frequency of uterine contractions and uterine tone. Contraction of the uterine wall
around bleeding vessels at the placental site produces haemostasis reduce blood loss.

• Ergometrine also increases contractions of the cervix.
• Following administration of therapeutic doses, intense titanic uterine contractions are produced and are usually
followed by periods of relaxation. Larger doses produce sustained, forceful contractions followed by only short or no
periods of relaxation.
• Produces vasoconstriction, mainly of post-capillary vessels. Central venous pressure is increased. Hypertension may
occur. Peripheral ischaemia and gangrene are rare.
• Produces arterial vasoconstriction by stimulation of alpha-adrenergic and serotonin receptors and inhibition of
endothelial-derived relaxation factor release
Question 25 Which one is not a recognised contraindication to the use of ergometrine?
A Severe heart disease B Severe liver disease

C Pregnancy induced hypertension D Essential hypertension
E Previous history of uterine rupture
Explanation
Ergometrine: Contraindications
Induction of labour and during the first and second stages of labour
Hypertensive disorders of pregnancy
Peripheral vascular disease or severe heart disease
Severe renal or hepatic impairment
Sepsis
Side-effects
Nausea & vomiting
Chest pain, palpitations, breathlessness
Hypertension with vasoconstriction
Stroke, myocardial infarction

E Rigors
Explanation
Carbetocin
Indications
Mechanism of action

Contraindications
Side-effects
Question 27
term
oxytocin oxytocin
ergometrin
Explanation
Question 28 Which one is not a contra-indication to the use of dinoprostone?
A Antepartum haemorrhage B Previous caesarean section

C Before 37 weeks gestation D Breech presentation
E Grand multiparity
Explanation
Dinoprostone: Contraindications
• Active vaginal bleeding or conditions associated with antepartum haemorrhage (placenta previa or placental
abruption)
• Known cephalo-pelvic disproportion
• Previous caesarean section or major uterine surgery
• Fetal compromise
• Multiple pregnancy
• Grand multiparity
• Ruptured membranes
• Fetal mal-presentation
• Active cardiac, pulmonary, renal or hepatic disease

Which one of the above statements regarding the dinoprostone vaginal delivery system
Question 29
(Propess) is not true?
Has a tape which is used to remove the delivery

A B Contains 10mg dinoprostone
system if necessary
Releases dinoprostone at a faster rate in women May be used for induction of labour in women
C D
with ruptured membranes with pre-labour rupture of the membranes at term
Releases dinoprostone at a rate of ~ 0.3mg per
E
hour
Explanation
Dinoprostone vaginal delivery system (PROPESS)
• Containing 10mg dinoprostone (Prostaglandin E 2 ) dispersed throughout a non-biodegradable matrix with withdrawal
tape to terminate drug action if necessary. On removal of the system from the vagina, it will have swollen to 2-3 times
its original size and be pliable.
• Controlled release at ~ 0.3mg per hour over 24 hours in women with intact membranes.
• Rate of release is higher and more variable in women with pre-labour rupture of membranes.
• Stored in the freezer
Dose
Question 30 The dinoprostone vaginal delivery system (PROPESS)

Should be inserted into the vagina using a water- Releases dinoprostone at the rate of 0.03mg per
A B
based lubricant hour
Should be ~50% of its original size when it is
C Can be stored at room temperature D
removed from the vagina after 24 hours
Contains dinoprostone within a biodegradable
E
matrix
Explanation
Dinoprostone vaginal delivery system (PROPESS)
• Containing 10mg dinoprostone (Prostaglandin E 2 ) dispersed throughout a non-biodegradable matrix with withdrawal
tape to terminate drug action if necessary. On removal of the system from the vagina, it will have swollen to 2-3 times
its original size and be pliable.
• Controlled release at ~ 0.3mg per hour over 24 hours in women with intact membranes.
• Rate of release is higher and more variable in women with pre-labour rupture of membranes.
• Stored in the freezer
Dose


A healthy 67 year old woman complains of urinary frequency, urgency and urge incontinence
Question 1
but no other symptoms. Which one of the above is the most appropriate treatment?
A Oxybutynin B Desmopressin
C Dimethyl sulfoxide D Oestradiol
E Megestrol
Explanation
• Dry mouth (88%)

• Blurred vision
• Arrhythmia
• Angioedema
Contra-indications
A healthy 52 year old woman has urodynamic stress incontinence which has not improved with
Question 2 physiotherapy. She is awaiting surgical treatment and would like medical treatment to reduce
the embarrassment of incontinence
A Dimethyl sulfoxide B Desmopressin

C Dimethyl sulfoxide D Tolterodine
E Duloxetine
Explanation
Duloxetin
Combined serotonin (5HT) and noradrenaline re-uptake inhibitor

Use results in:
• A significant reduction in incontinence episodes per week
• A significant reduction in social embarrassment and psychological impact of incontinence and a significant
improvement in quality of life
Side-effects
• GI disturbance particularly nausea and dry mouth
• Headache, decreased libido, anorgasmia
• Withdrawal reaction is characterised by headache, nausea, paraesthesia, dizziness and anxiety - drug should
not be stopped abruptly and dose should be reduced over a 2 week period
Contraindications
• Pregnancy, lactation
• Hepatic impairment
• Monoamine oxidase therapy
• Lowers seizure threshold therefore avoid in epilepsy
• Can enhance the anti-coagulant effects of warfarin
• Metabolised by the same enzymes as ciprofloxacin and fluvoxamine - avoid co-prescription
• Avoid co-prescription with SSRIs and tricyclic anti-depressants
NICE RECOMMENDATIONS
Duloxetine is not recommended as a first-line treatment for women with predominant stress incontinence.
Duloxetine should not routinely be used as a second-line treatment for women with stress incontinence, although
it may be offered as second-line therapy if women prefer pharmacological to surgical treatment or are not
suitable for surgical treatment.
If duloxetine is prescribed, women should be counselled about its adverse effects.
A healthy 52 year old woman complains of nocturia and nocturnal enuresis. Which one is the
Question 3
most appropriate treatment?
A Dimethyl sulfoxide B Norgestimate

C Amitriptyline D Duloxetine
E Mefenamic acid
Explanation
Tricyclic antidepressants
• Amitriptyline, imipramine, nortriptyline, lofepramine
• Have anti-cholinergic effects on the bladder and also sedative
• Useful in nocturia and nocturnal enuresis.
Contra-indications
• Arrhythmia
• Post-myocardial infarction
Main side-effects
• Drowsiness (may affect driving) and postural hypotension
• Effects of alcohol are enhanced
• Arrhythmias
• CNS side-effects including anxiety, dizziness and confusion
• Anti-muscarinic side-effects: dry mouth, blurred vision, constipation, urinary retention
A healthy 47 year old mother of 5 children complains of urinary leakage on coughing and
Question 4 straining. Pelvic floor physiotherapy has been unsuccessful and she has declined surgical
intervention. Which one is the most suitable treatment?

A Tolterodine B Duloxetine
C Solifenacin D Amantadine
E Imipramine
Explanation
Duloxetin
Use results in:
Side-effects
Contraindications
If duloxetine is prescribed, women should be counselled about its adverse effects
A healthy 32 year old woman with urinary incontinence is found to have detrusor over-activity
Question 5
on cystometry. Which one is the most suitable treatment?
A Raloxifene B Dimethyl sulfoxide

C Solifenacin D Duloxetine
E Imipramine
Explanation
• Dry mouth (88%)


• Blurred vision
• Arrhythmia
• Angioedema
Contra-indications
Question 6 A Combined 5HT noradrenaline re-uptake inhibitor
A Oxybutynin B Dimethyl sulfoxide

C Norgestimate D Duloxetine
E Amantadine
Explanation
Duloxetin
Use results in:
Side-effects
Contraindications
If duloxetine is prescribed, women should be counselled about its adverse effects.

E Flavoxate
Explanation
• Dry mouth (88%)

• Blurred vision
• Arrhythmia
• Angioedema
Contra-indications
Question 8 Tricyclic antidepressants (such as amitriptyline)
Are effective in the treatment of urinary stress Are contra-indicated in women with a cardiac
A B
incontinence arrhythmia
C Have anti-muscarinic effects on the bladder D Are associated with diarrhoea
Are the recommended treatment for interstitial
E
cystitis
Explanation
Tricyclic antidepressants
• Amitriptyline, imipramine, nortriptyline, lofepramine
• Have anti-cholinergic effects on the bladder and also sedative
• Useful in nocturia and nocturnal enuresis.
Contra-indications
• Arrhythmia

• Post-myocardial infarction
Main side-effects
• Drowsiness (may affect driving) and postural hypotension
• Effects of alcohol are enhanced
• Arrhythmias
• CNS side-effects including anxiety, dizziness and confusion
• Anti-muscarinic side-effects: dry mouth, blurred vision, constipation, urinary retention
Question 9 Which one of the above statements regarding dimethyl sulfoxide is true?
Results in symptomatic improvement in women

A Is administered directly into the bladder B
with stress incontinence
C Is a 5HT re-uptake inhibitor D Is a nor-adrenaline re-uptake inhibitor
E Has anti-cholinergic effects on the bladder
Explanation
Dimethyl Sulfoxide
• Used for symptomatic treatment of interstitial cystitis

• 50ml of 50% solution instilled into the bladder for 15 minutes then the bladder is emptied
• Treatment repeated at intervals of 2 weeks
• Associated with bladder spasm and hypersensitivity reactions
• Long-term use requires hepatic, renal and ophthalmic assessment every 6 months
Question 10 Which one of the above drugs is not known to precipitate or exacerbate urinary incontinence?
A Alcohol B Frusemide
C Diazepam D Amitriptyline
E Caffeine
Explanation
Drugs that may precipitate / exacerbate urinary incontinence
• Diuretics – increase volume of urine produced and exacerbate urgency, urge incontinence and nocturia
• Alpha-antagonists – relaxation of the urethral sphincter and worsen incontinence
• Alcohol – diuretic and impairs judgement and co-ordination. Exacerbates urinary frequency and urgency
• Sedatives including benzodiazepines – sedation and confusion associated with incontinence
• Caffeine is associated with over=active bladder
• Anti-cholinergic agents including anti-depressants with anti-cholinergic activity – reduce detrusor contractility and
associated with urinary retention

E GnRH
Explanation
Tranexamic acid
Contraindications
Side effects
Question 2 Which one of the above statements regarding mefenamic acid is true?

A Is an anti-fibrinolytic agent B
Is ineffective in copper IUCD associated heavy Is associated with reduced fertility with long-term
C D
menstrual bleeding use
E Is associated with hot flushes
Explanation
NSAIDS
Contraindications
Side-effects

• Renal failure
Question 3 Which one of the above drugs can virilise a female fetus?
A Tamoxefen B Raloxifene
C Mefenamic acid D Tranexamic acid
E Danazol
Explanation
Danazol
Contraindications
• Breastfeeding
Which one of the above drugs can be used to induce a medical menopause and treat
Question 4
endometriosis-related pelvic pain?
A Raloxifene B GnRH analogue

C Tamoxefen D Clomiphene citrate
E Cyproterone acetate
Explanation
GnRH analogues
FSH and LH release
Indications

Administration
Side-effects
• Headache
• Ovarian cysts

weeks
Explanation
GnRH analogues
FSH and LH release
Indications
Administration
Side-effects
• Headache
• Ovarian cysts

Which one of the above drugs suppresses pituitary LH production, hepatic sex hormone
Question 6
binding globulin production and is used to treat hirsutism?
A Flutamide B Spironolactone
C Gestrinone D GnRH analogue
E Combined oral contraceptive pill
Explanation
PHARMACOLOGICAL TREATMENT OF HIRSUTISM
• Combined oral contraceptive pill- suppress LH production and ovarian androgen synthesis; increase SHBG
production and progesterone inhibits 5-alpha reductase activity.
• Avoid COCP with androgenic progestogens such as norethisterone / levonorgestrel.
• Consider COCP with anti-androgenic progestogen cyproterone acetate.
• Cyproterone acetate should not be used on its own without effective contraception as it can emasculate a male fetus
- side-effects include weight gain, fatigue, breast tenderness, headache, GI upset, hepatotoxicity.
Question 7 Which one of the above statements regarding spironolactone is true?
A Has anti-androgenic activity B Is an aldosterone agonist

C It is a glucocorticoid D Is associated with hypokalaemia
E Is associated with hypertension
Explanation
Spironolactone - anti-androgen and aldosterone antagonist. Monitor BP and electrolytes in the first few weeks of
treatment - hypotension and hyperkalaemia are side-efects.
Flutamide - non-steroidal anti-androgen. Rare side effect - hepatotoxicity - check LFTs.
Finasteride - 5-alpha-reductase inhibitor - effective contraception required as can emasculate male fetus.

menopausal uterus
Explanation
TAMOXIFEN
Action

and carcinoma
Clinical use
Side-effects
Question 9
endometrial cancer?

E Spironolactone
Explanation
TAMOXIFEN
Action
and carcinoma
Clinical use
Side-effects
Question 10
E Nifedipine
Explanation
METHYLDOPA

Contraindications
• Depression
Side-effects
• Drug fever
Interactions
• Alcohol
Question 11 A Dihydropyridine calcium channel blocker
C Labetalol D Nifedipine
E Calcium gluconate
Explanation
NIFEDIPINE
• Dihydropyridine class of calcium channel blockers
• Inhibits the influx of extracellular calcium. This inhibits the contraction of smooth muscle cells, causing dilation of the
coronary and systemic arteries, increased oxygen delivery to the myocardial tissue and decreased total peripheral
resistance
• Rapidly and fully absorbed following oral administration.
• 92-98% protein-bound
• Half life 2h
• Hepatic metabolism via cytochrome P450 system to water-soluble, inactive metabolites accounting for 60 to 80% of
the dose excreted in the urine. The remainder is excreted in the faeces
• Grapefruit down regulates post-translational expression of CYP3A4, the major metabolizing enzyme of nifedipine.
Grapefruit can significantly increase serum levels of nifedipine and may cause toxicity
Side-effects
• Constipation
• Headache
• Palpitations

• Low mood and lethargy
Question 12 Serum levels of lithium are increased in women taking this anti-hypertensive drug
E Captopril
Explanation
CAPTOPRIL
Indications
Contraindications
• Pregnancy
Side-effects
• Hypotension
• Angioedema
• Hyperkalaemia
Interactions
Question 13 Non-competitive inhibitor of angiotensin converting enzyme
E None of the above
Explanation

ENALAPRIL
• Angiotensin-converting enzyme (ACE) inhibitor
• Prodrug, rapidly hydrolysed in the liver to enalaprilat following oral administration Enalaprilat is a potent, competitive
inhibitor of ACE
• 55-75%, absorption after oral administration, unaffected by food
• 50-60% of enalaprilat is bound to plasma proteins
• Excretion of enalapril is primarily renal
• Half life is < 2 hours for unchanged enalapril
• The terminal half life of enalaprilat is 35-38 hours while the effective half life following multiple doses is 11-14 hours.
Indications
Contraindications
• Pregnancy
• Use of ACE inhibitors that are prodrugs requires close monitoring in patients with deranged liver function
• Interactions and side-effects similar to captopril
Which one is the most appropriate treatment for a healthy 32 year old woman who is found to
Question 14
have detrusor over-activity on cystometry?

C Combined HRT D Tolterodine
E Duloxetine
Explanation
• Dry mouth (88%)

• Blurred vision
• Arrhythmia
• Angioedema
Contra-indications

E Flavoxate
Explanation
• Dry mouth (88%)

• Blurred vision
• Arrhythmia
• Angioedema
Contra-indications

hormone
C D
Explanation

Women should not take non-steroidal anti-inflammatory drugs for 8-12 days after taking this
Question 17
drug
A Drospirenone B Yasmin
C Norethisterone oenanthate D Mifepristone
E Misoprostol
Explanation
MIFEPRISTONE: CONTRA-INDICATIONS
• Suspected ectopic pregnancy
• Chronic adrenel insufficiency
• Long-term corticosteroid therapy
• Haemorrhagic disorders
• Anti-coagulant therapy
• Smokers over the age of 35 (avoid smoking / alcohol 2 days before and on the day of prostaglandin administration)
• Hepatic / renal impairement
• Avoid aspirin / NSAIDS for at least 8-12 days after mifepristone.
Question 18

E Drospirenone
Explanation
4) Pregnancy - 60 / 100,000
Question 19 Risk ofvenous thrombo-embolism in a healthy pregnant woman

A 5 in 100,000 B 15 in 100,000
C 20 in 100,000 D 25 in 100,000
E 60 in 100,000
Explanation
4) Pregnancy - 60 / 100,000

Question 20
contraception

Explanation
Cardiovascular
• Stroke
Malignancy
Endocrine
GI Disorders
Rheumatological
A Family history of myocardial infarction B Personal history of DVT

Treated breast cancer with no recurrence after 10
C Gestational diabetes in previous pregnancy D
years
E BMI 45 kg/m2

Explanation
Cardiovascular
Malignancy
GI Disorders
Rheumatological
A healthy 23 year old woman wishes to use the combined oral contraceptive pill as soon as
Question 22
possible. She has a regular 28 day cycle and her LMP was 3 days ago.

days
C D
48h 24h
E
72h
Explanation
When to start COCP
A healthy 33 year old woman wishes to start using the progestogen-only contraceptive implant
Question 23 as soon as possible. She has a regular 28 day cycle and her LMP was 17 days ago. She has
been using condoms.

A B Start immediately & no additional contraception
days
C D
24h 48h
E Start immediately, additional contraception for

72h
Explanation
When to start progestogen only implants & injectables
Ideally in the 1st 5 days of cycle. No additional contraception needed.
Can be inserted at any other time provided woman is not pregnant. Use barrier methods or abstinence for 7 days
Can be started up to and including day 21 post partum without need for additional contraceptive cover. If started
after day 21, use barrier methods or abstinence for 7 days.
Can be started within 5 days of termination of pregnancy or miscarriage (< 24wks gestation) without need for
additional contraception. If after 5 days, advise barrier methods or abstinence for 7 days
Question 24
contraception.
Start immediately, additional contraception for 5 Start immediately, additional contraception for 7
A B
days days
24h
E
48h
Explanation
A 23 year old woman attends for induction of labour at 42 weeks gestation. One hour after
Question 25 administration of vaginal prostaglandin, she is having 8 contractions in 10 minutes and there
are fetal heart rate decelerations. Which one is the most appropriate treatment?
A Atosiban B Dinoprostone
C Dinoprost D Magnesium sulphate
E Terbutaline
Explanation
Atosiban

• Much more expensive compared to ritodrine or nifedipine
Question 26 Which one of the above is not a recognised side-effect of atosiban?
A Nausea & vomiting B Hypertension

C Hypotension D Hyperglycaemia
E Hot flushes
Explanation
OXYTOCIN ANTAGONISTS
Atosiban - competitive oxytocin / vasopressin antagonist
Associated with significant increase in the number of women remaining undelivered at 24, 48h and 7 days after
Infant mortality was not significantly different at >28 weeks gestation but was significantly INCREASED in the
Similar efficacy to beta agonists but with fewer cardiovascular side-effects
Much more expensive compared to ritodrine or nifedipine
Contraindications
Eclampsia & severe pre-eclampsia
Intra-uterine infection
Fetal death
Antepartum haemorrhage
Pre-term premature rupture of the membranes
Side-effects: nausea, vomiting, tachycardia, hypotension, headache, hyperglycaemia, hot flushes, injection site
reaction
Administration: intra-venous
Loading dose of 6.75mg over 1 minute then
18mg/hour for 3 hours then
6mg/hour for maximum total treatment duration of 48 hours

E Rigors
Explanation

Carbetocin
Indications
Mechanism of action
Contraindications
Side-effects
Question 28 Which one is not a recognised effect of active management of the third stage of labour?
A Increased risk of raised blood pressure B Increased need for blood transfusion
C A shortening of the length of the third stage D Reduced risk of severe post-partum haemorrhage
E Increased risk of nausea and vomiting
Explanation
Third stage of labour: Active Vs Expectant management
• Active management consists of
• Administration of uterotonic agent (oxytocin)
• Delivery of the placenta by controlled cord traction
• Whether early clamping of the cord is part of active management of the third stage is controversial
Compared with expectant management, active management is associated with

• Shorter third stage (mean difference, ~10 minutes)
• Reduced risk of postpartum hemorrhage (NNT= 12)
• Reduced risk of severe postpartum hemorrhage (NNT = 57)
• Reduced risk of anaemia (NNT = 27)
• Reduced need for blood transfusion (NNT = 65)
• Reduced need for additional uterotonic medications (NNT = 7)
• Increased risk of maternal nausea (number needed to harm [NNH] = 15)
• Increased risk of vomiting (NNH = 19)
• Increased risk of raised blood pressure (NNH = 99)
• No difference in risk of retained placenta
• No difference in neonatal outcomes
Question 29
term
oxytocin oxytocin

ergometrin
Explanation
Question 30 Misoprostol
A Is a synthetic prostaglandin E2 analogue B Is not licensed for use in pregnancy in the UK

Is available in the UK in 50 microgram and 25
C D Can be administered by im injection
microgram oral tablets
Is as effective as im oxytocin in preventing post-
E
partum haemorrhage
Explanation
Misoprostol
• Synthetic prostaglandin E1 analogue
• Originally developed for the prevention of NSAID-induced gastric ulcers by inhibiting gastric acid secretion and
improving the mucus barrier
• Stimulates uterine contractions and the ripening of the cervix
• Not licensed for use in pregnancyin the UK.
• Oral misoprostol usually comes in tablets of 100 micrograms or 200 micrograms.Using small doses (50 micrograms)
will involve dividing the tablet using a pill cutter, making accurate dosage difficult.
• Used for induction of labour, termination of pregnancy and prevention / treatment of post-partum haemorrhage
• Less expensive than the other commonly used pharmacological agents for inducing labour and does not require
refrigeration, making it advantageous in resource-poor settings
• Can be administered orally, vaginally or rectally
• Neither oral nor rectal administration of misoprostol has been shown to be as effective as injectable uterotonics in
preventing postpartum hemorrhage
• Use of misoprostol is associated with
• Increased need for additional uterotonic medications (NNH = 22)
• Increased side effects including shivering (NNH = 7), vomiting (NNH = 225), diarrhoea (NNH = 258), and elevated
body temperature (NNH = 18).

Question 1 Which one of the above statements regarding tranexamic acid is true?
Should be discontinued if the woman develops

A Typically causes constipation B
disturbance of colour vision
C Is a recognised treatment for dysmenorrhoea D Is a non-steroidal anti-inflammatory drug
Should be discontinued if the woman complains
E
of nausea
Explanation
nexamic acid
Contraindications
Side effects
Which one of the above drugs has been shown to reduce menstrual blood loss by ~50% in
Question 2
women with heavy menstrual bleeding?
A Mefenamic acid B Raloxifene

C Tranexamic acid D Tamoxefen
E Clomiphene citrate
Explanation
Tranexamic acid
Contraindications
Side effects
Mefenamic acid reduces blood loss by ~ 25%.

Which one of the above drugs is effective in reducing menstrual blood loss but is associated
Question 3
with significant androgenic side-effects?
A Danazol B Tamoxefen
C Raloxifene D Mefenamic acid
E Tranexamic acid
Explanation
nazol
Contraindications
• Breastfeeding
Question 4
loss?

E GnRH analogue
Explanation
GnRH analogues
FSH and LH release
Indications
Administration

Side-effects
• Headache
• Ovarian cysts
Question 5 Which one of the above statements about GnRH analogues is true?
Inhibit LH release on initial commencement of

A Stimulate FSH release with long-term use B
treatment
Result in up-regulation of GnRH receptors in the
C D Result in amenorrhoea with long-term use
anterior pituitary gland
E Are effective in treating menopausal symptoms
Explanation
GnRH analogues
FSH and LH release
Indications
Administration
Side-effects
• Headache
• Ovarian cysts
Which one of the above drugs has androgenic, anti-oestrogenic and anti-progestogenic
Question 6
activity?
A Clomiphene citrate B Cyproterone acetate

C Medroxyprogesterone acetate D Finasteride

E Gestrinone
Explanation
Gestrinone
• 19-nortestosterone derivative, androgenic anti-oestrogen and anti-progestogen.
• Significantly reduces menstrual loss but not first line therapy.
• Not licensed for the treatment of menorrhagia.
• Associated with androgenic side-effects (milder than danazol) and can virilise female fetus therefore barrier
contraception is essential.
Contraindications
• Pregnancy & breastfeeding
• Severe cardiac and hepatic impairment
Which one of the above drugs is used to induce ovulation in women with polycystic ovary
Question 7
syndrome?
A Eflornithine hydrochloride B Mefenamic acid

C Tranexamic acid D Clomiphene citrate
E Flutamide
Explanation
ANTI-OESTROGENS
Anti-oestrogen drugs have varying effects on different organs / tissues. In addition to anti-oestrogenic
effects, the majority also have oestrogenic effects on some tissues.
CLOMIPHENE CITRATE
Action
Antagonises negative feedback effects of oestrogen on the pituitary gland and hypothalamus, resulting in
increased GnRH, FSH and LH levels which stimulate the ovaries and induce ovulation
Non-steroidal anti-oestrogen with weak oestrogenic effects
Active orally, has long half life and significant plasma concentrations can be detected 1 month after a single
50mg dose
Administered from days 2-6 of the cycle
Use should be limited to a 12 months course
Clinical use
Ovulation induction in women with sub-fertility secondary to anovulation (typically polycystic ovary syndrome).
Contraindications
Hepatic disease, ovarian cysts and hormone dependent tumours
Side-effects
Visual disturbance, hot flushes, ovarian hyperstimulation, multiple pregnancy, hair loss, breast tenderness,
headache
Question 8 Which one of the above statements regarding clomiphene citrate is not true?

Is typically administered from days 2 to 6 of the
A B Should be used for a minimum of 6 months
menstrual cycle
C D Can cause hot flushes
Is a recognised cause of ovarian
E
hyperstimulatuon syndrome
Explanation
ANTI-OESTROGENS
CLOMIPHENE CITRATE
Action
• Antagonises negative feedback effects of oestrogen on the pituitary gland and hypothalamus, resulting in
• Non-steroidal anti-oestrogen with weak oestrogenic effects
• Active orally, has long half life and significant plasma concentrations can be detected 1 month after a single
50mg dose
• Administered from days 2-6 of the cycle
• Use should be limited to a 12 months course
Clinical use
• Ovulation induction in women with sub-fertility secondary to anovulation (typically polycystic ovary syndrome).
Contraindications
• Hepatic disease, ovarian cysts and hormone dependent tumours
Side-effects
• Visual disturbance, hot flushes, ovarian hyperstimulation, multiple pregnancy, hair loss, breast tenderness, headache
Drug that is effective in inducing ovulation in women with polycystic ovary syndrome and is
Question 9
typically associated with gastro-intestinal side-effects
A Gestrinone B Metformin
C Raloxifen D Medroxy-progesterone acetate
E Cyproterone acetate
Explanation
Metformin
• Insulin-sensitising agent, shown to have beneficial effects on reproductive function (ovulation induction) and insulin
resistance.
• Ovulation rate is significantly higher with metformin compared to placebo
• Ovulation rate with metformin + clomiphene is significantly higher than with clomiphene alone.
• However, this is confounded by the inclusion of women who were known to be clomiphene resistant in some trials.
• Addition of metformin to clomiphene no more effective than clomiphene alone as primary treatment
Metabolic effects of metformin

• Weight is not significantly altered
• Blood pressure - both systolic and diastolic blood pressure are significantly reduced
• Fasting insulin is significantly reduced

• Total cholesterol is unchanged but LDL cholesterol is significantly reduced. HDL cholesterol and triglycerides were
unaffected
• GI side-effects are more common with metformin, particularly nausea and vomiting.
In women with anovulation secondary to polycystic ovary syndrome, treatment with metformin
Question 10
is associated with which one of the above effects / side-effects?
A A significant reduction in weight B A significant rise in systolic BP

C A significant reduction in fasting insulin levels D Constipation
E Triplet pregnancy
Explanation
Metformin
• Insulin-sensitising agent, shown to have beneficial effects on reproductive function (ovulation induction) and insulin
resistance.
• Ovulation rate is significantly higher with metformin compared to placebo
• Ovulation rate with metformin + clomiphene is significantly higher than with clomiphene alone.
• However, this is confounded by the inclusion of women who were known to be clomiphene resistant in some trials.
• Addition of metformin to clomiphene no more effective than clomiphene alone as primary treatment
Metabolic effects of metformin

• Weight is not significantly altered
• Blood pressure - both systolic and diastolic blood pressure are significantly reduced
• Fasting insulin is significantly reduced
• Total cholesterol is unchanged but LDL cholesterol is significantly reduced. HDL cholesterol and triglycerides were
unaffected
• GI side-effects are more common with metformin, particularly nausea and vomiting.

E GnRH
Explanation
Tranexamic acid
Contraindications
Side effects
Question 2 Which one of the above statements about danazol is true?
Is contraindicated in women with a history of

A Is effective in treating idiopathic hirsutism B
If taken in during pregnancy can emasculate a
C Is recommended for use for up to 5 years D
male fetus
Is associated with proliferation of the
E
endometrium
Explanation
Danazol
Contraindications
• Breastfeeding

Question 3 Which one of the above drugs can virilise a female fetus?
A Tamoxefen B Raloxifene
C Mefenamic acid D Tranexamic acid
E Danazol
Explanation
Danazol
Contraindications
• Breastfeeding
Question 4 GnRH analogues are used in which one of the above circumstances?
Treatment of heavy menstrual bleeding due to

A Treatment of endometriosis-related pelvic pain B
copper IUCD
C Long-term reversible contraception D Treatment of hirsutism in women with PCOS
Suppression of lactation in women with fetal
E
death in the third trimester
Explanation
GnRH analogues
FSH and LH release
Indications

Administration
Side-effects
• Headache
• Ovarian cysts
Question 5 Which one of the above drugs is an anti-androgenic progestogen?
A Tamoxefen B Clomiphene citrate

C Cyproterone acetate D Flutamide
E Finasteride
Explanation
Which one of the above drugs suppresses pituitary LH production, hepatic sex hormone
Question 6
binding globulin production and is used to treat hirsutism?
A Flutamide B Spironolactone
C Gestrinone D GnRH analogue
E Combined oral contraceptive pill
Explanation

Question 7 Which one of the above statements regarding clomiphene citrate is not true?
Is typically administered from days 2 to 6 of the

A B Should be used for a minimum of 6 months
menstrual cycle
C D Can cause hot flushes
Is a recognised cause of ovarian
E
hyperstimulatuon syndrome
Explanation
ANTI-OESTROGENS
CLOMIPHENE CITRATE
Action
• Antagonises negative feedback effects of oestrogen on the pituitary gland and hypothalamus, resulting in
• Non-steroidal anti-oestrogen with weak oestrogenic effects
• Active orally, has long half life and significant plasma concentrations can be detected 1 month after a single
50mg dose
• Administered from days 2-6 of the cycle
• Use should be limited to a 12 months course
Clinical use
• Ovulation induction in women with sub-fertility secondary to anovulation (typically polycystic ovary syndrome).
Contraindications
• Hepatic disease, ovarian cysts and hormone dependent tumours
Side-effects
• Visual disturbance, hot flushes, ovarian hyperstimulation, multiple pregnancy, hair loss, breast tenderness, headache

menopausal uterus
Explanation
TAMOXIFEN
Action
and carcinoma

Clinical use
Side-effects
Question 9
endometrial cancer?

E Spironolactone
Explanation
TAMOXIFEN
Action
and carcinoma
Clinical use
Side-effects
Question 10 Which drug can mask the symptoms of hypoglycaemia in diabetics?
E None of the above
Explanation
Labetalol HCl
• Racemic mixture of four isomers, two of which are inactive
• Selective competitive alpha-1 blocker
• Non-selective competitive beta blocker
• Ratio of alpha to beta blockade ~ 1:3 after oral administration and 1:7 after intravenous administration
• Block activity of myocardial beta-receptors (beta-1) and within bronchial and vascular smooth muscle (beta-2)
• Blocks activity in alpha-1-receptors within vascular smooth muscle
• Results in decreased arterial blood pressure and peripheral vascular resistance
• Does not cause significant reduction in resting heart rate, cardiac output, or stroke volume

• Completely absorbed following oral administration with peak plasma levels occurring 1 to 2 hours after oral
administration
• Can be administered orally, by iv injection and iv infusion
• Undergoes significant hepatic first pass metabolism. These metabolites are present in plasma and are excreted in the
urine, and via the bile, into the faeces
• 50% protein-bound
• Plasma half life 6-8 hours
Indications
• First-line treatment for hypertension in pregnancy and post-partum
Contraindications
• Asthma & COAD
• Marked bradycardia
• Severe peripheral vascular disease
• May mask symptoms of hypoglycaemia in diabetics
• Avoid in patients with hepatic impairment – severe hepatic injury reported. Consider reducing dose in renal
impairment.
Question 11
E Nifedipine
Explanation
METHYLDOPA
Contraindications
• Depression
Side-effects
• Drug fever

Interactions
• Alcohol
Question 12 Which drug has side-effects including tachycardia and flushing?
A Captopril B Enalapril
C Hydralazine D Methyldopa
E Labetalol
Explanation
YDRALAZINE
preeclampsia
retention.
Indications
Interactions
Contraindications
• SLE
Side-effects
Question 13
drospirenone

E Captopril
Explanation
CAPTOPRIL
Indications
Contraindications
• Pregnancy
Side-effects
• Hypotension
• Angioedema
• Hyperkalaemia
Interactions
Question 14 Which one is a recognised side-effect of captopril?

A Dry cough B Hypokalaemia

C Constipation D Positive Coomb’s test
E Depression
Explanation
CAPTOPRIL

Indications
Contraindications
• Pregnancy
Side-effects
• Hypotension
• Angioedema
• Hyperkalaemia
Interactions
Question 15 Captopril
Is a non-competitive inhibitor of Angiotensin

A Is a pro-drug B
Converting Enzyme
C Causes an increase in plasma rennin activity D Is mainly metabolised by the kidneys
E Is an aldosterone antagonist
Explanation
CAPTOPRIL
Indications
Contraindications
• Pregnancy
Side-effects
• Hypotension

• Angioedema
• Hyperkalaemia
Interactions
Question 16 Non-competitive inhibitor of angiotensin converting enzyme
E None of the above
Explanation
ENALAPRIL
• Angiotensin-converting enzyme (ACE) inhibitor
• Prodrug, rapidly hydrolysed in the liver to enalaprilat following oral administration Enalaprilat is a potent, competitive
inhibitor of ACE
• 55-75%, absorption after oral administration, unaffected by food
• 50-60% of enalaprilat is bound to plasma proteins
• Excretion of enalapril is primarily renal
• Half life is < 2 hours for unchanged enalapril
• The terminal half life of enalaprilat is 35-38 hours while the effective half life following multiple doses is 11-14 hours.
Indications
Contraindications
• Pregnancy
• Use of ACE inhibitors that are prodrugs requires close monitoring in patients with deranged liver function
• Interactions and side-effects similar to captopril
Question 17 Anti-D immunoglobulin
Is best administered by intramuscular injection to Is not needed if termination of pregnancy occurs

A B
the gluteal muscle before 9 weeks gestation
Is not recommended if pregnancy is terminated Should be administered following salpingectomy
C D
medically before 9 weeks gestation for ectopic pregnancy
Should not be administered following a
E
spontaneous complete miscarriage at 14 weeks
Explanation
Recommendations for anti-D prophylaxis

• Intramuscular anti-D Ig is best given into the deltoid muscle as injections into the gluteal region often only reach
the subcutaneous tissues and absorption may be delayed.
• Anti-D Ig should be given as soon as possible after the sensitising event but always within 72 hours. If it is not
given before 72 hours, every effort should still be made to administer the anti-D Ig, as a dose given within 9-10
days may provide some protection
Therapeutic termination of pregnancy: Anti-D Ig should be given to all non-sensitised RhD negative women
having a therapeutic termination of pregnancy, whether by surgical or medical methods, regardless of gestational
age
Ectopic pregnancy: Anti-D Ig should be given to all non-sensitised RhD negative women who have an ectopic
pregnancy
Spontaneous miscarriage: Anti-D Ig should be given to all non-sensitised RhD negative women who have a
spontaneous complete or incomplete abortion after 12 weeks of pregnancy. Anti-D Ig should be given when
there has been an intervention to evacuate the uterus. On the other hand, the risk of immunisation by
spontaneous miscarriage before 12 weeks' gestation is negligible when there has been no instrumentation to
evacuate the products of conception and anti-D Ig is not required in these circumstances
Threatened miscarriage: Anti-D Ig should be given to all non-sensitised RhD negative women with a threatened
miscarriage after 12 weeks of pregnancy. Where bleeding continues intermittently after 12 weeks' gestation, anti-
D Ig should be given at 6-weekly intervals. Routine administration of anti-D Ig is not recommended before 12
weeks gestation. However it may be prudent to administer anti-D Ig where bleeding is heavy or repeated or
where there is associated abdominal pain particularly if these events occur as gestation approaches 12 weeks
A 25 year old woman complains of urinary urgency and urge incontinence. Bladder re-training
Question 18
has been ineffective. Which one is the most appropriate treatment?
Which one is the most appropriate treatment for a healthy 32 year old woman who is found to
Question 19
have detrusor over-activity on cystometry?

C Combined HRT D Tolterodine
E Duloxetine
Explanation
• Dry mouth (88%)

• Blurred vision
• Arrhythmia
• Angioedema

Contra-indications
E Flavoxate
Explanation
• Dry mouth (88%)

• Blurred vision
• Arrhythmia
• Angioedema
Contra-indications

hormone
C D

Explanation
Question 22 Spironolactone derivative used in combined oral contraceptive pills
E Desogestrel
Explanation
DOSE
Oestrogen:
Progestogen:
2nd generation
Norethisterone 1mg
3rd generation
Desogestrel 150mcg
Gestodene 150mcg
Norgestimate 250mcg
Drospirenone 3mg
E Desogestrel

Explanation
DOSE
Oestrogen:
Progestogen:
2nd generation
Norethisterone 1mg
3rd generation
Desogestrel 150mcg
Gestodene 150mcg
Norgestimate 250mcg
Drospirenone 3mg
Women should not take non-steroidal anti-inflammatory drugs for 8-12 days after taking this
Question 24
drug
E Misoprostol
Explanation
Question 25

E Drospirenone

Explanation
4) Pregnancy - 60 / 100,000
Question 26
contraception.
A B
days days
24h
E
48h
Explanation

A 23 year old woman attends for induction of labour at 42 weeks gestation. One hour after
Question 27 administration of vaginal prostaglandin, she is having 8 contractions in 10 minutes and there
are fetal heart rate decelerations. Which one is the most appropriate treatment?
A Atosiban B Dinoprostone
C Dinoprost D Magnesium sulphate
E Terbutaline
Explanation
Atosiban

• Much more expensive compared to ritodrine or nifedipine
Question 28 Which one is not a recognised side-effect of beta agonists used for tocolysis?
A Hypokalaemia B Hyperkalaemia
C Maternal tachycardia D Maternal pulmonary oedema
E Palpitations
Explanation
BETA-AGONISTS
• Now less commonly used because of side-effects and availability of safer alternatives
• Cross placenta and cause fetal tachycardia, hyperglycaemia and hyperinsulinaemia
• Maximum recommended dose is 350 micrograms/min - use minimum dose necessary to inhibit uterine contractions
and maintain maternal pulse <140bpm. Starting dose 50 micrograms/min
• 5% dextrose recommended as infusing solution
Recommended monitoring:
1) Maternal pulse every 15 min

2) BP every 15 min initially
3) Blood glucose 4 hourly
4) Fluid in-put out-put chart
5) U & E every 24h
6) Auscultation of lung fields every 4h
Side-effects
Commonest - palpitations, tremor, nausea, vomiting, headache, restlessness, tachycardia (dose-related).
Heart rate should not exceed 140bpm because of associated risk of pulmonary oedema. Associated with
hypotension.
Rare side-effects include pulmonary oedema (secondary to anti-diuretic effect and excessive fluid in-put), myocardial
ischaemia, hyperglycaemia and hyperinsulinaemia.
Pulse pressure is increased (increased cardiac out-put + peripheral vasodilatation)

Question 29 Antenatal corticosteroids to reduce neonatal mortality and morbidity are not recommended
If intra-uterine growth restriction is diagnosed at If intra-uterine growth restriction is diagnosed at

A 32 weeks and delivery is expected in the next B 35 weeks and delivery is expected within 24
week hours
If a woman with insulin-dependent diabetes
If the woman presents with contractions at 34+3
C D presents with pre-term labour at 36 weeks
weeks gestation
gestation T
If elective caesarean section is planned for 38
E
weeks because of previous stillbirth
Explanation
ANTENATAL CORTICOSTEROIDS
Indications
• Women between 24+0 and 34+6 weeks of gestation who are at risk of preterm birth.
• Consider treatment in women between 23+0 and 23+6 weeks of gestation who are at risk of preterm birth
• Pregnancies affected by IUGR between 24+0and 35+6 weeks of gestation at risk of delivery
• Most effective in reducing RDS in pregnancies that deliver between 24 hours and 7 days after administration of the
second dose
• However, the risk of neonatal death is still reduced if delivery occurs within the first 24 hours and therefore should still
be given even if delivery is expected within this time
• No reduction in neonatal death, RDS or intraventricular haemorrhage is seen in infants delivered more than 7 days
after treatment with antenatal corticosteroids
• Antenatal corticosteroids should be given to all women for whom an elective caesarean section is planned prior to
38+6 weeks of gestation.

E Rigors
Explanation
Carbetocin
Indications
Mechanism of action
Contraindications
Side-effects


Question 1 Labetalol
Should not be used in women with chronic renal

A Has a plasma half life of ~1 hour B
disease
C Is a non-competitive beta blocker D Blocks beta-1 receptors in the myocardium
E Is metabolised mainly by the kidneys
Explanation
abetalol HCl
administration
Indications
Contraindications
• Asthma & COAD
impairment.
Question 2 Which drug can mask the symptoms of hypoglycaemia in diabetics?
E None of the above
Explanation
Labetalol HCl

administration
Indications
Contraindications
• Asthma & COAD
impairment.
Question 3 Which one of the above is not a recognised side-effects of methyldopa?
A Dry mouth B Drowsiness

C Parkinsonism D SLE-like syndrome
E Hypomania
Explanation
METHYLDOPA
Contraindications
• Depression
Side-effects

• Drug fever
Question 4 Which anti-hypertensive drug is typically associated with depression?
A Methyldopa B Labetalol
C Nifedipine D Atenolol
E Oxprenolol
Explanation
METHYLDOPA
Contraindications
• Depression
Side-effects
• Drug fever
Question 5 Hydralazine
A Is a centrally-acting vasodilator B Has no direct effects on cardiac function

C Is not absorbed if administered orally D Has oral bio-availability which is independent of

acetylator phenotype
E Is a calcium channel blocker
Explanation
HYDRALAZINE
preeclampsia
retention.
Indications
Interactions
Contraindications
• SLE
Side-effects
Question 6 Inhibits influx of extracellular calcium in vascular smooth muscle
E Calcium gluconate
Explanation
NIFEDIPINE
resistance

• Half life 2h
Side-effects
• Constipation
• Headache
• Palpitations
Question 7 Normal plasma concentration of magnesium
A 0 – 0.05 mM B 0.8 – 1.0 mM

C 1.5 – 1.8 mM D 2.0 – 4.0 mM
E 4.0 – 5.0 mM
Explanation
NIFEDIPINE
resistance
• Half life 2h
Side-effects
• Constipation
• Headache
• Palpitations
Question 8 Concentration of magnesium associated with cardiac arrest
A 2.0 – 4.0 mM B 4.0 – 5.0 mM

C 5.0 – 7.0 mM D > 7.5 mM
E > 12 mM
Explanation

Monitoring of MgSO4 therapy
Clinical
• Hourly tendon reflexes. Use arm reflexes if regional anaesthesia
• Renal function
• Hourly urine outputCardio-respiratory
• ECG during and for 1 hour after loading dose
• SO2 continuously
Magnesium Levels & toxicity
Magnesium levels should be checked every 6-12 hours. Close monitoring is required in women with < 100 ml urine
output in 4h, serum urea > 10 mM, and those with known renal impairment
0.8 – 1.0 mM: Normal plasma levels
2 – 4 mM: Therapeutic range
2.5 – 5.0 mM: ECG changes with prolonged P-Q interval and widened QRS complexes
4 - 5 mM: Diminished tendon reflexes, muscle weakness, diplopia, slurred speech.
Action: Stop infusion, check Mg levels
>5 mM: Loss of tendon reflexes
> 7.5 mM: Sino-atrial and atrio-ventricular block. Respiratory paralysis and CNS depression
>12 mM: Cardiac arrest
With respect to the use of anti-D immunoglobulin in unsensitised Rhesus negative women who
Question 9
are bleeding during pregnancy
A dose of 1250 IU should be administered if A dose of 1500 IU should be administered if

A B
bleeding occurs before 20 weeks bleeding occurs after 20 weeks
A Kleihauer test is not required if bleeding occurs Anti-D immunoglobulin should be administered
C D
at 24 weeks within 72h of the onset of bleeding
If the woman presents 5 days after the onset of
E vaginal bleeding, anti-D immunoglobulin should
not be administered
Explanation
Use of anti-D immunoglobulin
RHESUS BLOOD GROUP
• Six major antigens - C, D, E; c,d,e. However, there are at least 50 antigens in this blood group system
• An individual with the C antigen cannot have the c antigen; same for D & E antigens
• D antigen is most antigenic - individuals with D antigen are Rhesus positive. 16% of Caucasians are Rhesus negative
while 0.3% of Asians are Rhesus negative
• Immune response to Rhesus antigens is slow and peak antibody titres are attained 2-4 months after exposure.
Transfusion reaction in an unsensitized individual is therefore delayed
• D antigen causes severe Rhesus disease. C & E antigens can cause mild fetal haemolysis. Usually the first
pregnancy is not affected, but may be if the mother had received incompatible blood products
• The offspring of two Rh negative individuals must be Rh negative. The offspring of a Rh negative and a Rh positive
individual may be Rh negative as the Rh positive parent may be heterozygous
Mechanism of action of anti-D immunoglobulin
• Administered anti-D immunoglobulin binds to and removed Rh +ve fetal red cells before the maternal immune system
encounters these cells and becomes sensitized.
Recommended route / dose
• im, some available iv; s/c if bleeding disorder
Sensitizing events
• At least 250 IU before 20 weeks
• At least 500 IU after 20 weeks + Kleihauer test
• Administer within 72h of event
• 500IU covers 4ml fetal red cells

• 100-125 IU per additional ml of fetal red cells
Post-partum
• 500 IU within 72h of birth if baby Rh +ve
• Need a robust system to identify Rh +ve babies and ensure treatment is not missed or delayed
Where bleeding continues intermittently after 12 weeks gestation anti D should be given at 6 weekly intervals
Antenatal corticosteroids administered to women at increased risk of pre-term delivery at 24 –

Question 10
34 weeks gestation
A Reduce the risk of neonatal death by 10% B Reduce the risk of necrotising enterocolitis
C Increase the risk of early-onset neonatal sepsis D Increase the risk of chorioamnionitis
E Increase the risk of cerebral palsy
Explanation
Benefits of antenatal corticosteroids
Pre-term pregnancies
• Reduce the risk of neonatal death by 31%
• Reduce the risk of RDS by 44%
• Reduce the risk of intraventricular haemorrhage by 46%
• Reduce the risk of necrotising enterocolitis
• Reduce the need for respiratory support and neonatal intensive care admissions
• Reduce the risk of systemic infections in the first 48 hours of life
• Single course of antenatal corticosteroids is not associated with any significant short-term or long-term maternal or
fetal risks
• Children who had been exposed to multiple as compared with single courses of antenatal corticosteroids do not differ
significantly in physical or neurocognitive measures.
• However, multiple courses are associated with a nonsignificant higher risk of cerebral palsy among children

Question 1 Which one of the above statements regarding tranexamic acid is true?
Should be discontinued if the woman develops

A Typically causes constipation B
disturbance of colour vision
C Is a recognised treatment for dysmenorrhoea D Is a non-steroidal anti-inflammatory drug
Should be discontinued if the woman complains
E
of nausea
Explanation
Tranexamic acid
Contraindications
Side effects
E GnRH
Explanation
Tranexamic acid
Contraindications
Side effects
Question 3 GnRH analogues are used in which one of the above circumstances?

Treatment of heavy menstrual bleeding due to
A Treatment of endometriosis-related pelvic pain B
copper IUCD
C Long-term reversible contraception D Treatment of hirsutism in women with PCOS
Suppression of lactation in women with fetal
E
death in the third trimester
Explanation
GnRH analogues
FSH and LH release
Indications
Administration
Side-effects
• Headache
• Ovarian cysts
Question 4
loss?

E GnRH analogue
Explanation
GnRH analogues
FSH and LH release
Indications

Administration
Side-effects
• Headache
• Ovarian cysts

weeks
Explanation
GnRH analogues
FSH and LH release
Indications
Administration
Side-effects
• Headache
• Ovarian cysts


menopausal uterus
Explanation
TAMOXIFEN
Action
and carcinoma
Clinical use
Side-effects
Question 7 Which one of the above drugs has anti-oestrogenic activity in the breast?
Question 8
endometrial cancer?

E Spironolactone
Explanation
TAMOXIFEN
Action
and carcinoma
Clinical use
Side-effects

Question 9 Which one of the above drugs is a selective oestrogen receptor modulator?
Which one of the above drugs is used to prevent breast cancer recurrence and is not
Question 10
associated with an increased risk of endometrial cancer?
A Flutamide B Finasteride
C Spironolactone D Gestrinone
E Raloxifen
Explanation
RALOXIFEN
This is the archetypal Selective oEstrogen Receptor Modulator (SERM) developed to maximise the anti-
oestrogenic effects on specific tissues without the potentially damaging oestrogenic effects on other tissues
Clinical use
Used in the treatment and prevention of post-menopausal osteoporosis
Oestrogen-antagonist in breast therefore not associated with increased risk of breast cancer
Oestrogen antagonist / neutral on the uterus – therefore not associated with increased risk of endometrial cancer
(unlike tamoxifen).
Does not relieve hot flushes
Side-effects
Hot flushes, leg cramps, thromboembolism, GI upset and flu-like symptoms
Question 11 Cyproterone acetate
A Can be used on its own as effective contraception B Has progestogenic activity

C Is an anti-oestrogen D
Is typically administered by intra-muscular
E
injection
Explanation
ANTI-ANDROGENS
Clinical use
• Anti-androgens may emasculate a male fetus therefore women must be informed of this risk and use effective
contraception while on treatment
Cyproterone acetate

Question 12 Which anti-hypertensive drug should not be used post-partum?
A Methyldopa B Labetalol
C Nifedipine D Atenolol
E Oxprenolol
Explanation
METHYLDOPA
Contraindications
• Depression
Side-effects
• Drug fever
Question 13
E Nifedipine
Explanation
METHYLDOPA

Contraindications
• Depression
Side-effects
• Drug fever
Interactions
• Alcohol
Which anti-hypertensive drug is a recognised cause of profound hypotension and fetal

Question 14
distress?
E Methyldopa
Explanation
HYDRALAZINE
preeclampsia
retention.

Indications
Interactions
Contraindications
• SLE
Side-effects
Question 15
drospirenone
E Captopril
Explanation
CAPTOPRIL
Indications
Contraindications
• Pregnancy
Side-effects
• Hypotension
• Angioedema
• Hyperkalaemia
Interactions

Question 16 When using magnesium sulphate to treat eclampsia
The loading dose should be administered over 30

A B The maintenance dose is 1mg/minute
minutes
If seizures recur, magnesium sulphate infusion Recurrent seizure can be treated by increasing
C D
should be stopped the maintenance dose
Loading dose should be omitted if renal function
E
is impaired
Explanation
MAGNESIUM SULPHATE
excitability
• 2+
relaxation
Indications
Dose
infusion rate to 1.5 g or 2.0 g/hour.
Question 17 Which one of the above statements regarding magnesium sulphate is not true?
A Should be used for at least 24 hours after the last B Can be administered by intravenous infusion or

seizure intra-muscular injection
When administered intravenously, anticonvulsant Causes direct inhibition of action potentials in
C D
effects occur after at least 15 minutes skeletal muscle
Is excreted by the kidneys at a rate proportional to
E
the glomerullar filtration rate
Explanation
MAGNESIUM SULPHATE
excitability
• 2+
relaxation
Indications
Dose
infusion rate to 1.5 g or 2.0 g/hour.
E Flavoxate
Explanation

• Dry mouth (88%)

• Blurred vision
• Arrhythmia
• Angioedema
Contra-indications
E Desogestrel
Explanation
DOSE
Oestrogen:
Progestogen:
2nd generation
Norethisterone 1mg
3rd generation
Desogestrel 150mcg
Gestodene 150mcg
Norgestimate 250mcg
Drospirenone 3mg

A Gestodene B Drospirenone
C Yasmin D Norethisterone oenanthate
E Mifepristone
Explanation
3rd generation progestogens in COCP
• Desogestrel 150mcg
• Gestodene 150mcg
• Norgestimate 250mcg
MIFEPRISTONE (RU486)
• Derivative of norethindrone (19-norsteroid) - similar chemical structure to progesterone / glucocorticoids.
•
• Progesterone / glucocorticoid antagonist.
•
• Like progesterone, binds to the progesterone receptor causing dimerisation of the receptor and binding to
progesterone response elements of progesterone responsive genes. Unlike progesterone, however, transcription
is inhibited.
Question 21

E Drospirenone
Explanation
4) Pregnancy - 60 / 100,000
Question 22 Contra-indication (UKMEC 3 or 4) to use of the progestogen-only pill
A Age over 45 years B Age 20 years and smoking 15 cigarettes per day
C SLE with positive anti-phospholipid antibodies D Family history of myocardial infarction

E Family history of DVT
Explanation
Progestogen-only Pills: UKMEC 3 – Risks outweigh benefits
Cardiovascular
Malignancy
GI Disorders
Rheumatological

Question 23
contraception

Explanation
Cardiovascular
• Stroke
Malignancy
Endocrine
GI Disorders
Rheumatological
SLE with unknown anti-phospholipid antibody

A Primary Raynaud’s disease B
status
C Gestational diabetes in previous pregnancy D BMI 45 kg/m2
E 12 weeks after vaginal delivery and breastfeeding

Explanation
Cardiovascular
Malignancy
GI Disorders
Rheumatological
Question 25
contraception.
A B
days days
24h
E
48h
Explanation
Which drug is recommended for use in induction of labour at term in women with an
Question 26
unfavourable cervix?
A Vaginal gemeprost 1mg B Vaginal prostaglandin E2 gel 2mg

C Oral prostaglandin E2 D Intramuscular carboprost
E Vaginal carboprost

Explanation
Dinoprostone (prostaglandin E2)
• Naturally occurring prostaglandin
• Available as tablets, gels and sustained release delivery systems
• Rapidly metabolised locally within tissues. Any drug reaching the systemic circulation is metabolised by the lungs and
liver. The products of dinoprostone metabolism are eliminated by the kidneys
• Half life less than 5 minutes
• Administered intravaginally
• Stimulates myometrial contractions similar to those of normal labour
• Mechanism of direct myometrial stimulation is unknown but are likely to be through alteration of intracellular calcium
concentrations
• Also has local cervical effects including softening, effacement, and dilation (ripening of the cervix) by modulating
collagen degradation caused by secretion of the enzyme collagenase
Indications
• Induction of labour at term
Gemeprost
• 16, 16-dimethyl-trans-delta2 PGE1 methyl ester
• Prostaglandin E1 analogue
• Stimulates uterine contractions and causes ripening of the cervix within 3 hours
of vaginal administration
• Decreases placental and uterine blood flow secondary to uterine stimulation
• Effective cervical dilator in the first and second trimester
• Plasma levels are very low following vaginal administration
• 12 - 28% of the vaginal dose is eventually absorbed into the circulation, and 50%
of this is excreted in the urine
• The unabsorbed dose is largely washed out in the urine or found in pads used to
absorb vaginal blood loss
• Store in freezer below -10 C. Allow to warm at room temperature for 30 minutes
before administration
Indications
• Cervical ripening prior to first trimester surgical termination of pregnancy. 1mg
into the posterior vaginal fornix 3h before surgery
• Second trimester termination of pregnancy. 1mg into the posterior vaginal fornix
every 3h for a maximum of 5 doses. Second course may begin 24h after start of
treatment. If second course fails, pregnancy should be terminated by another
means
• Management of intra-uterine fetal death in the second trimester. 1mg into the
posterior vaginal fornix every 3h for a maximum of 5 doses.
Question 27 Ergometrine maleate
A Is an oxytocin analogue B Stimulates contraction of the cervix

Causes hypotension if administered by rapid
C Increases uterine blood flow D

E Binds to oxytocin receptors in the uterus
Explanation
Ergometrine Maleate
• An amine ergot alkaloid.
• Stimulates contractions of uterine and vascular smooth muscle
• Increases the amplitude and frequency of uterine contractions and uterine tone. Contraction of the uterine wall
around bleeding vessels at the placental site produces haemostasis reduce blood loss.
• Ergometrine also increases contractions of the cervix.
• Following administration of therapeutic doses, intense titanic uterine contractions are produced and are usually
followed by periods of relaxation. Larger doses produce sustained, forceful contractions followed by only short or no
periods of relaxation.
• Produces vasoconstriction, mainly of post-capillary vessels. Central venous pressure is increased. Hypertension may
occur. Peripheral ischaemia and gangrene are rare.
• Produces arterial vasoconstriction by stimulation of alpha-adrenergic and serotonin receptors and inhibition of
endothelial-derived relaxation factor release
Question 28 Which one is not a recognised contraindication to the use of ergometrine?
A Severe heart disease B Severe liver disease

C Pregnancy induced hypertension D Essential hypertension
E Previous history of uterine rupture
Explanation
Ergometrine: Contraindications
Induction of labour and during the first and second stages of labour
Hypertensive disorders of pregnancy
Peripheral vascular disease or severe heart disease
Severe renal or hepatic impairment
Sepsis
Side-effects
Nausea & vomiting
Chest pain, palpitations, breathlessness
Hypertension with vasoconstriction
Stroke, myocardial infarction

E Rigors
Explanation
Carbetocin

Indications
Mechanism of action
Contraindications
Side-effects
Question 30
term
oxytocin oxytocin
ergometrin
Explanation

E Desogestrel
Explanation
DOSE
Oestrogen:
Progestogen:
2nd generation
Norethisterone 1mg
3rd generation
Desogestrel 150mcg
Gestodene 150mcg
Norgestimate 250mcg
Drospirenone 3mg

A Gestodene B Drospirenone
C Yasmin D Norethisterone oenanthate
E Mifepristone
Explanation
3rd generation progestogens in COCP
• Desogestrel 150mcg
• Gestodene 150mcg
• Norgestimate 250mcg
MIFEPRISTONE (RU486)
• Derivative of norethindrone (19-norsteroid) - similar chemical structure to progesterone / glucocorticoids.
•
• Progesterone / glucocorticoid antagonist.

•
• Like progesterone, binds to the progesterone receptor causing dimerisation of the receptor and binding to
progesterone response elements of progesterone responsive genes. Unlike progesterone, however, transcription
is inhibited.
Question 3 Which drug is contra-indicated in women with a bleeding disorder?
E Misoprostol
Explanation
Question 4 Absolute contra-indication (UKMEC 4) to use of the combined oral contraceptive pill
12 weeks after vaginal delivery and not

A Age 37 years and smoking 3-5 cigarettes per day B
breastfeeding
12 weeks after caesarean section and not Age 20 years with a history of focal migraine at
C D
breastfeeding the age of 15 years
E Recent molar pregnancy
Explanation
CONTRA-INDICATIONS TO COCP
UKMEC 4 – unacceptable health risks or absolute contraindications
Personal
• Age over 35 years and smoking ≥15 cigarettes / day
Cardiovascular
• Multiple risk factors for arterial cardiovascular risk e.g. older age, diabetes, hypertension, smoking.
• Hypertension: Systolic BP > 160mmHg or diastolic > 94 mmHg
• VTE risk: Personal history of VTE, major surgery with prolonged immobilisation, thrombophilia
• Current or history of ischaemic heart disease, stroke or peripheral vascular disease
Neurological
• Migraines with aura at any age
Endocrine
• Diabetes mellitus: Retinopathy, nephropathy, neuropathy or diabetes > 20 yrs duration (otherwise IDDM and
NIDDM are UKMEC 2).

Malignancy
• Current breast cancer or other oestrogen / progesterone-sensitive tumour
GI Disorders
• Active viral hepatitis and severe (de-compensated cirrhosis). Hepatocellular adenoma & hepatoma
Rheumatological
• SLE with positive or unknown anti-phospholipid antibodies (SLE on its own or with severe thrombocytopaenia or
use of immuno-suppressive therapy are UKMEC 2)
• Raynaud’s disease with lupus anticoagulant (Primary Raynaud,s disease = UKMEC 1 and Raynaud’s disease
without lupus anticoagulant = UKMEC 2)
Pregnancy
• Within 6 weeks post-partum and breast-feeding
• Note that gestational trophoblastic disease with decreasing or undetectable HCG, persistently elevated HCG or
malignant disease are all UKMEC 1 (UNRESTRICTED USE) for COCP

Question 5
contraception
A SLE with positive anti-phospholipid antibodies B Family history of myocardial infarction

C Family history of DVT D Gestational diabetes in previous pregnancy
E BMI of 35 kg/m2
Explanation
ogestogen-only Injectables: UKMEC 3 – Risks outweigh benefits
Cardiovascular
• Stroke
Malignancy
Endocrine
GI Disorders
Rheumatological
SLE with unknown anti-phospholipid antibody

A Primary Raynaud’s disease B
status
C Gestational diabetes in previous pregnancy D BMI 45 kg/m2
E 12 weeks after vaginal delivery and breastfeeding
Explanation

ogestogen-only Implants: UKMEC 3 – Risks outweigh benefits
Cardiovascular
Malignancy
GI Disorders
Rheumatological
A 2 tablets of progestogen-only pill B Levonorgestrel

C Levonorgestrel-releasing intra-uterine device D Gestodene
E Desogestrel
Explanation
A healthy 34 year old woman wishes to start the progestogen-only oral contraceptive pill as
Question 8
soon as possible. She has a regular 28 day cycle and her LMP was 10 days ago

days
C D
48h 24h
E
72h
Explanation
When to start COCP

A healthy 23 year old woman wishes to discuss contraception after a vaginal delivery at term.
Question 9
She is breastfeeding and wishes to use the progestogen-only oral contraceptive pill

A B Start 21 days after delivery
days
C Start after 6 weeks D Start 6 months after delivery
Start 21 days after delivery with additional
E
contraception for 7 days
Explanation
When to start COCP
Question 10
contraception.
A B
days days
24h
E
48h
Explanation


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This Copy is for Dr.

Options for Questions 1-1

A(Correct answ er: D)

A Tranexamic acid B Mefenamic acid

A(Correct answ er: B)

This Copy is for Dr. Mohamed ElHodiby

Options for Questions 3-3

Reduces menstrual blood loss by ~50% in women

A(Correct answ er: D)

Question 4 Which one of the above statements about danazol is true?

Options for Questions 4-4

Is contraindicated in women with a history of

This Copy is for Dr. Mohamed ElHodiby

A(Correct answ er: B)

A Tranexamic acid B Mefenamic acid

A(Correct answ er: E)

This Copy is for Dr. Mohamed ElHodiby

Options for Questions 6-6

Should not be used on their own for longer than 6

A(Correct answ er: C)

Question 7 Which one of the above statements regarding tamoxifen is true?

Options for Questions 7-7

Has anti-oestrogenic effects on the post-

This Copy is for Dr. Mohamed ElHodiby

A Tranexamic acid B Tamoxifen

A(Correct answ er: B)

A(Correct answ er: B)

Question 10 Cyproterone acetate

Options for Questions 10-10

This Copy is for Dr. Mohamed ElHodiby

A(Correct answ er: B)

Options for Questions 11-11

A(Correct answ er: A)

This Copy is for Dr. Mohamed ElHodiby

A(Correct answ er: C)

Question 13 Magnesium sulphate

Options for Questions 13-13

This Copy is for Dr. Mohamed ElHodiby

A(Correct answ er: A)

Question 14 Anti-D immunoglobulin

Options for Questions 14-14

Should not be administered to Rhesus negative Should be administered at weekly intervals if a

A(Correct answ er: A)

This Copy is for Dr. Mohamed ElHodiby

Question 15 Which one is not an anti-cholinergic drug?

Options for Questions 15-15

A(Correct answ er: D)

• Dry mouth (88%)

This Copy is for Dr. Mohamed ElHodiby

Options for Questions 16-16

Is a shorter-acting analogue of anti-diuretic

A(Correct answ er: D)

Options for Questions 17-17

Results in symptomatic improvement in women

A(Correct answ er: A)

• Used for symptomatic treatment of interstitial cystitis

This Copy is for Dr. Mohamed ElHodiby

Options for Questions 18-18

A(Correct answ er: E)

A Medroxyprogesterone acetate B Norethisterone

A(Correct answ er: D)

1) Healthy woman not taking COCP - 5 / 100,000

2) Second generation COCP user - 15 / 100,000