Statistics Busyspr

This Copy is for Dr.
Mohamed ElHodiby
Question 1 The incidence of ectopic pregnancy in the UK
Options for Questions 1-1
A 1-1.2% B 1.5-2%
C 3.0 – 5.5% D 7.5 – 9.5%
E 10-15%
A(Correct answ er: A)
Explanation
SCARRIAGE
• Occurs in 10–20% of clinical pregnancies
• When these highly sensitive HCG assays are used early, the prevalence of pregnancy loss increases to about 60-
70%
• About 80% of miscarriages occur in the first trimester
• Incidence of ectopic pregnancy is 11.0 per 1,000 pregnancies
Impact of obstetric history
• The risk of miscarriage in women in their first pregnancy or women in whom the last pregnancy ended in a live birth is
5%
• In multiparous women in whom all previous pregnancies have ended in a live birth, the risk of miscarriage is slightly
lower (4%)
• If the last pregnancy ended in miscarriage, the risk of miscarriage is 20%
• If all previous pregnancies have ended in miscarriage, the risk of miscarriage is about 25%
Question 2 The proportion of miscarriages that occur in the first trimester
A 5.0 – 10% B 15 – 20%

C 25 – 35% D 45 – 50%
E 75 – 80%
A(Correct answ er: E)
Explanation
MISCARRIAGE
70%
5%
lower (4%)
This Copy is for Dr. Mohamed ElHodiby

Question 3 Which one of the above statements regarding the risk of miscarriage is true?
The risk is about 5% in women whose last The risk is about 15% in women whose last
A B
pregnancy ended in a live birth pregnancy ended in a live birth
The risk is about 75% in women in whom all The risk is 1% in multiparous women in whom all
C D
previous pregnancies have ended in miscarriage previous pregnancies have ended in live birth
The risk is 12.5% in women in whom all previous
E
pregnancies have ended in miscarriage
Explanation
MISCARRIAGE
70%
5%
lower (4%)
Impact of maternal age

• Age: 12-19 years: 11% risk of miscarriage
• Age: 20-24 years: 9%
• Age: 25-29 years: 10%
• Age: 30-34 years: 12%
• Age: 35-39 years: 20%
• Age: 40-44 years: 41%
• Age: 45 or more: 75%
Women who conceive using donor eggs have miscarriage rates that are similar to the egg donor's age and not the
recipient's age, indicating that miscarriages are increased due to aging oocytes
Question 4 Which one of the above is not associated with an increased risk of miscarriage?
A Low pre-pregnancy BMI B Feeling stressed during pregnancy

C Working during pregnancy D Regular alcohol consumption during pregnancy
E Previous termination of pregnancy
A(Correct answ er: C)
Explanation
After adjustment for confounding factors, the following are independently associated with increased risk of
miscarriage:
1. High maternal age
2. Previous miscarriage

3. Termination of pregnancy
4. Subfertility
5. Assisted conception
6. Low pre-pregnancy body mass index
7. Regular or high alcohol consumption
8. Feeling stressed (including trend with number of stressful or traumatic events)
9. High paternal age
10. Changing partner
Question 5 Which one of the above is associated with an increased risk of ectopic pregnancy?
A High maternal age B High paternal age

C Use of progestogen-only contraception D Previous medical termination of pregnancy
E Previous caesarean section
Explanation
RISK FACTORS FOR ECTOPIC PREGNANCY
• PID
• IUCD
• Sterilisation
• Tubal surgery
• Previous ectopic
• Assisted reproduction
• Mini-pill
All current contraceptive users, including IUCD are less likely to have an ectopic pregnancy than sexually active
women not using contraception
IUCD users (except MIRENA) are 3 times more likely to have an ectopic pregnancy than users of other
contraceptives
Use of depot medroxyprogesterone acetate is associated with a lower risk of ectopic pregnancy than the mini-pill but
higher than the COCP
The stillbirth rate for twin births in the UK

0.5 per 1000 total

A B 1.2 per 1000 total births
births
5.1 per 1000 total
C D 7.5 per 1000 total births
births
10.0 per 1000 total
E
births
A(Correct answ er: D)

Question 7 The neonatal mortality rate for twin births in the UK
A 5.1 per 1000 total births B 7.5 per 1000 total births
C 11 per 1000 total births D 17 per 1000 total births
E 24 per 1000 total births
Explanation
• In 2008, there were 799,047 total births and 795,004 live births in the UK.
• There were 4,043 stillbirths, 6,025 perinatal deaths and 2,557 neonatal deaths.
• There were 1,982 early neonatal deaths and 575 late neonatal deaths.
• Since 2000, there has been a statistically significant downward trend (p<0.001) in the perinatal mortality rate in the
United Kingdom, from 8.3 per 1,000 total births in 2000 to 7.5 per 1,000 total births in 2008
• This is due to both, a statistically significant decrease (p<0.001) in the early neonatal mortality rate (from 2.9 in 2000
to 2.5 in 2008 per 1,000 live births)
• There has been a statistically significant decrease (p<0.001) in the stillbirth rate (from 5.4 in 2000 to 5.1 in 2008 per
1,000 total births)
• There has also been a statistically significant downward trend (p<0.001) in the perinatal mortality rate for twin births in
the United Kingdom since 2000.
• The stillbirth rate for twin births has also shown a statistically significant downward trend (p<0.001) from 16.7 per
1,000 total births in 2000 to 11.2 per 1,000 total births in 2008
• The neonatal mortality rate for twin births has shown a statistically significant downward trend (p<0.001) from 21.5
per 1,000 live births in 2000 to 17.0 per 1,000 live births
• There is wide variation in the adjusted mortality rates between Strategic Health Authorities (SHAs) in England
• Mothers of black ethnic origin are 2.3 [95% CI: 2.1, 2.6] times more likely to have a stillbirth and 2.3 [2.0, 2.7] times
more likely to have a neonatal death than mothers of white ethnic origin
• Mothers of Asian ethnic origin are 1.8 [1.6, 1.9] times more likely to have a stillbirth and 1.7 [1.5, 1.9] times more
likely to have a neonatal death than mothers of white ethnic origin
• There are about 500 intra-partum deaths each year (8.8% of all stillbirths). CMACE recommends that all term intra-
partum deaths with no sign of a major congenital anomaly be fully investigated locally with a view to identifying
whether there were any avoidable factors and to ensure that lessons are learned.
Question 8 The perinatal mortality rate in the UK
A 0.5 per 1000 total births B 1.2 per 1000 total births
C 5.1 per 1000 total births D 7.5 per 1000 total births
E 10.0 per 1000 total births
Explanation

1,000 total births)
Question 9 With respect to perinatal mortality in the UK in 2008
The perinatal mortality rate is 0.75 per 1000 total

A B The stillbirth rate is 5.1 per 1000 total births
births
The early neonatal mortality rate is 2.5 per 1000 The stillbirth rate in twins is 5.5 per 1000 total
C D
total births births
E There are ~ 2 million live births per year in the UK
A(Correct answ er: B)
Explanation
1,000 total births)

Question 10 The proportion of cases of infertility for which no cause can be found
A 1% B 10%
C 14% D 18%
E 23%
Explanation
Epidemiology of infertility
• Infertility is failure to conceive after frequent unprotected sexual intercourse for two years
• The conception rate per menstrual cycle is fecundability, a measure of fertility
• The prevalence of infertility in European countries is around 14%
• In the general population, 84% of women would conceive within one year of regular unprotected sexual intercourse
while 92% conceive after two years and 93% after three years
• Primary infertility: in couples who have never conceived: 40% of cases.
• Secondary infertility: in couples who have previously conceived: 60% of cases
• Male factor infertility: 35%
• Female factor infertility: 35%
• Combined male + female factor infertility: 20%
• Unexplained infertility: 10%
Question 11 With respect to the epidemiology of sub-fertility
The prevalence of sub-fertility in the UK is around 75% of women conceive within 1 year of regular
A B
2% unprotected intercourse
92% of women would conceive within 2 years of A male factor alone is identified in 10% of couples
C D
regular unprotected intercourse with sub-fertility
In about 30% of couples with sub-fertility, no
E
cause is identified
Explanation
Epidemiology of infertility
• Infertility is failure to conceive after frequent unprotected sexual intercourse for two years
• The conception rate per menstrual cycle is fecundability, a measure of fertility

• The prevalence of infertility in European countries is around 14%
• In the general population, 84% of women would conceive within one year of regular unprotected sexual intercourse
while 92% conceive after two years and 93% after three years
• Primary infertility: in couples who have never conceived: 40% of cases.
• Secondary infertility: in couples who have previously conceived: 60% of cases
• Male factor infertility: 35%
• Female factor infertility: 35%
• Combined male + female factor infertility: 20%
• Unexplained infertility: 10%
Question 12 The contraceptive option used by 1 in 4 women aged 16 – 49 years in the UK
A Male condom B Female condom

C Oral contraceptive pill D Sterilization
E Partner sterilization
Explanation
Epidemiology of contraception
Contraceptive use in the UK in women aged 16-49 years, 2008-9
Contraceptive Uptake
Oral contraceptive (COCP + Progestogen-only) 25% (16% COCP)
Male condom 25%
IUCD 6%
Withdrawal 4%
Injection 3%
Implant 1%
Rhythm / Persona 2%
Hormonal IUS 2%
Sterilisation 6%
Partner sterilization 11%
58% of women aged 16-49 years use at least one non-surgical method
75% of women aged 16-49 years use at least one method of contraception
These figures have been unchanged over the last 10 years
Question 13 With respect to the uptake of contraception in women aged 16-49 years in the UK
The contraceptive implant is used by 10% of 58% of women use at least one non-surgical
A B
women method
Partner sterilization is used by about 1% of
C D Hormonal implants are used by 15% of women
women

One in four women use the combined oral
E
contraceptive pill
Explanation
Male condom 25%
IUCD 6%
Withdrawal 4%
Injection 3%
Implant 1%
Rhythm / Persona 2%
Hormonal IUS 2%
Sterilisation 6%
Question 14 The commonest viral sexually transmitted infection in the UK
A Gonorrhoea B Chlamydia
C Genital warts D Genital herpes
E Genital candidiasis
Explanation
Sexually transmitted infections
• The total number of STIs diagnosed per year continues to rise
• Young people aged 15-24 years are most affected by STIs. ~2/3 of new STI diagnoses in women and ½ of those
diagnosed in men were in those aged under 25.
• Rates of acute STIs were highest urban areas, particularly London.
Genital Chlamydial trachomatis
• Commonest STI diagnosed in the UK with 348.7 new cases per 100,000 population
• In 2009 there were 217, 570 new chlamydia diagnoses
• A National Chlamydia Screening Programme (NCSP) for sexually active women and men under 25 years of age has
been in operation in England since 2003 and about one in ten of those screened were found to be positive
• Untreated, 10-40 per cent of women with genital chlamydial infection will develop pelvic inflammatory disease (PID)
which could result in tubal factor infertility, ectopic pregnancy and chronic pelvic pain
Genital warts
• Caused by HPV, mainly types 6 and 11
• There were 91, 257 new cases diagnosed in 2009
• Commonest viral STI in the UK and second commonest STI with a gradual increase in cases since the 1970s.

• The rate of new diagnoses was 148.7 per 100,000 population, with the highest rates in women 16-19 and men aged
20-24.
• The rate of new diagnoses appears to be increasing in the over 45 age group
Genital herpes
• There were 30,126 new cases diagnosed in 2009
• The rate of new diagnoses was 49.1 per 100,000 population with the highest rates in women aged 16-19 and 20-24
• The rate of new diagnoses has increased in the over 45 age group over the last 10 years
• Changes in sexual behaviour where oral sex is becoming more common and a decreased immunity in young people
to HSV-1 have contributed to a rise in incidence
Gonorrhoea
• The overall rate of new diagnoses was 27.7 per 100,000 population, with the highest rates in men aged 20-24 and
women aged 16-19
Syphilis
• The number of new cases have increased by over 600 per cent in the last 10 years.
• Men accounted for 88 per cent of the diagnoses with ~50% of these cases were in men who have sex with men.
• The overall rate of new diagnoses was 3.8 per 100,000 population. The highest rates were in men aged 25-34 and
35-44
HIV & AIDS
• 6,630 new diagnoses of HIV in the UK in 2009
• 54 per cent of infections were acquired through heterosexual intercourse
• 68% of heterosexual infections were acquired outside the UK
• 42 per cent of infections were acquired through sex between men. This group remains most at risk of acquiring HIV
within the UK.
• There were 547 AIDS diagnoses and 516 HIV-related deaths in 2009.
With respect to the grading of evidence from intervention studies, which one of the above is
Question 15
level 2++?
Evidence from well-conducted case-control

A Evidence from a panel of world-class experts B
studies
Evidence from well-conducted cohort studies with Evidence from a well-conducted randomized trial
C D
a very low risk of confounding with a very low risk of bias
Evidence from a randomized trial with a high risk
E
of bias
Explanation
Levels of evidence for intervention studies
• 1++: High-quality meta-analyses, systematic reviews of randomised controlled trials (RCTs), or RCTs with a very low
risk of bias
• 1+: Well-conducted meta-analyses, systematic reviews of RCTs, or RCTs with a low risk of bias
• 1-: Meta-analyses, systematic reviews of RCTs, or RCTs with a high risk of bias
• 2++: High-quality systematic reviews of case–control or cohort studies; high-quality case–control or cohort studies
with a very low risk of confounding, bias or chance and a high probability that the relationship is causal
• 2+: Well-conducted case–control or cohort studies with a low risk of confounding , bias or chance and a moderate
probability that the relationship is causal
• 2-: Case–control or cohort studies with a high risk of confounding, bias or chance and a significant risk that the
relationship is not causal
• 3: Non-analytical studies (e.g. case reports, case series)
• 4: Expert opinion, formal consensus

Question 16 With respect to the levels of evidence for the accuracy of diagnostic tests
A Level Ia refers to evidence from randomized trials B Level 1 studies are systematic reviews
Level 1 studies use blind comparisons of the test Homogeneity means all the studies were
C D
with a gold standard undertaken in the same population
Level Ia refers to studies undertaken by an
E organization which is different from the one that
originally developed the test
Explanation
s of evidence for accuracy of diagnostic tests
Ia: Systematic review (with homogeneity) of level-1 studies. Homogeneity means there are minor or no variations in
the directions and degrees of results between individual studies that are included in the systematic review.
Level-1 studies are studies that use a blind comparison of the test with a validated reference standard (‘gold’
standard) in a sample of patients that reflects the population to whom the test would apply.
Ib: Level-1 studies

II: Level-2 studies or systematic reviews of level-2 studies. Level-2 studies are studies that have only one of the
following:
• narrow population (the sample does not reflect the population to whom the test would apply)
• use a poor reference standard (defined as that where the ‘test’ is included in the ‘reference’, or where the ‘testing’
affects the ‘reference’)
• the comparison between the test and reference standard is not blind
• case–control studies
III: Level-3 studies or systematic reviews of level-3 studies. Level-3 studies are studies that have at least two or three
of the features of level 2 studies
IV: Consensus, expert committee reports or opinions and/or clinical experience without explicit critical appraisal; or
based on physiology, bench research or ‘first principles’
Question 17 With respect to the levels of evidence for the accuracy of diagnostic tests
Level 3 studies typically use a validated gold

A standard and a sample that reflects the population B Level III evidence is evidence from level 3 studies
in whom the test would be applied
Level III evidence is evidence from level 2b
C D Level 2 studies use a validated gold standard
studies
In level 1 studies, the sample of patients used
E does not reflect the population to whom the test
would apply
Explanation
Levels of evidence for accuracy of diagnostic tests

Ib: Level-1 studies

following:
Question 18 The rate of pre-eclampsia in women in their first pregnancy

A 1 in 50 B 1 in 25
C 1 in 10 D 1 in 5
E 1 in 2
Explanation
Hypertensive disorders of pregnancy
• Chronic hypertension is hypertension that is present at the booking visit or before 20 weeks or if the woman is
already taking antihypertensive medication when referred to maternity services.
• Gestational hypertension is new hypertension presenting after 20 weeks without significant proteinuria
• Pre-eclampsia is new hypertension presenting after 20 weeks with significant proteinuria.
• Severe pre-eclampsia is pre-eclampsia with severe hypertension and/or with symptoms, and/or biochemical and/or
haematological impairment.
• Significant proteinuria is if there is more than 300 mg protein in a 24-hour urine collection or more than 30 mg/mmol
in a spot urinary protein : creatinine sample.
Mild hypertension: diastolic blood pressure 90–99 mmHg, systolic blood pressure 140–149 mmHg
Moderate hypertension: diastolic blood pressure 100–109 mmHg, systolic blood pressure 150–159 mmHg
Severe hypertension: diastolic blood pressure 110 mmHg or greater, systolic blood pressure 160 mmHg or greater.
• Chronic hypertension occurs in ~2% of pregnancies
• Gestational hypertension occurs in 4.2% - 7.9% of pregnancies
• Pre-eclampsia affects 4.1% of women in their first pregnancy and 1.7% of women in their second or subsequent
pregnancy
• Overall, hypertensive disorders affect up to 10% of pregnancies and there is evidence that the rate may be increasing
• About 1/3 of severe maternal morbidity in the UK is secondary to hypertensive disorders
Question 19 Which one is a moderate risk factor for pre-eclampsia?
A Family history of pre-eclampsia B Family history of essential hypertension

C Type II diabetes D Type I diabetes
E Essential hypertension

Explanation
Risk factors for pre-eclampsia
Women at high risk include those with:
• Hypertensive disease during a previous pregnancy
• Chronic kidney disease
• Autoimmune disease such as systemic lupus erythematosis or antiphospholipid syndrome
• Type 1 or type 2 diabetes
• Chronic hypertension
Women at moderate risk include
• First pregnancy
• Age 40 years or older
• Pregnancy interval of more than 10 years
• BMI of 35 kg/m² or more at first visit
• Family history of pre-eclampsia
• Multiple pregnancy
Women with more than one moderate risk factor should be considered to be at high risk.
Question 20 Which one is not a moderate risk factor for pre-eclampsia?
A Age 42 years B Pregnancy interval of 12 years

C First pregnancy D BMI over 35 kg/m2 at booking
E Gestational hypertension in a previous pregnancy
Explanation
• First pregnancy
Women with more than one moderate risk factor should be considered to be at high risk
Question 21 Which one of the above is not a high risk factor(s) for pre-eclampsia?
43 year old in second pregnancy with pregnancy

A B First pregnancy in a 42 year old
interval of 12 years
C Twin pregnancy D Type I diabetes

E Type II diabetes
Explanation
• First pregnancy
Women with more than one moderate risk factor should be considered to be at high risk.
Question 22 With respect to diabetes mellitus in pregnancy
The majority of pregnancies affected by diabetes Diabetes affects 0.2 – 0.5% of pregnancies in the
A B
are due to pre-existing type 2 diabetes UK
Pre-existing type 2 diabetes affects 0.1% of births Pre-existing type 1 diabetes affects 1% of births in
C D
in the UK the UK
The prevalence of type 1 diabetes is decreasing
E
in the UK
Explanation
Diabetes mellitus in pregnancy
• Diabetes affects 2–5% of pregnancies
• Pre-existing type 1 diabetes occurs in 0.27% of births
• The prevalence of type 1 and type 2 diabetes is increasing
• Type 2 diabetes is increasing in certain minority ethnic groups especially people of African, black Caribbean, South
Asian, Middle Eastern and Chinese family origin)
• Gestational diabetes occurs in ~3.5% of births
• About 87.5% of pregnancies complicated by diabetes are, therefore due to gestational diabetes, with 7.5% being due
to pre-existing type 1 diabetes and 5% due to pre-existing type 2 diabetes.
Question 23 The proportion of births affected by pre-existing type 1 diabetes mellitus
Question 24 The proportion of births affected by pre-existing type 2 diabetes
A 0.01-0,03% B 0.05-0.1%

C 0.1-0.3% D 1-2%
E 3-5%
Explanation
Question 25 The proportion of pregnancies affected by diabetes mellitus in the UK
A 0.1-0.3% B 2-5%
C 5-7% D 10-20%
E 30-50%
Explanation
Question 26 Which one is associated with poor pregnancy outcome in women with pre-existing diabetes?
A Diabetic nephropathy B Recurrent hypoglycaemia

C Severe hypoglycaemia during pregnancy D Unplanned pregnancy
Use of progesterone-only contraception in the 12
E
months prior to pregnancy
Explanation

Women with type 1 and type 2 diabetes have an increased risk of adverse pregnancy outcomes (miscarriage, fetal
congenital anomaly and perinatal death)
Maternal social deprivation is associated with poor pregnancy outcome for women with type 1 or type 2 diabetes
Women with pre-existing complications of diabetes are more likely to have a poor pregnancy outcome. However,
nephropathy, recurrent hypoglycaemia and severe hypoglycaemia during pregnancy were not associated with poor
pregnancy outcome
Social and lifestyle factors associated with poor pregnancy outcome include
• Unplanned pregnancy
• No contraceptive use in the 12 months prior to pregnancy
• No preconception folic acid
• Smoking
• Sub-optimal approach of the woman to her diabetes prior to pregnancy
• Sub-optimal approach of the woman to her diabetes during pregnancy
Question 27 With respect to pre-term birth
Over 75% of pre-term births occur before 28

A 1 in 20 babies are born pre-term B
weeks gestation
The majority of extremely pre-term babies are
C The incidence of pre-term birth is decreasing D
large-for-dates
20% of women who have a pre-term birth will
E have another pre-term birth in their subsequent
pregnancy
Explanation
In England and Wales
• 8% (1 in 13) of live births are born preterm
• 94% of singleton babies born extremely preterm are of very low birthweight, whereas fewer than 1% of those born at
term are
• 93% of preterm births occur after 28 weeks of gestation, but 6% occur between 22 and 27 weeks, and just under 1%
occur before 22 weeks.
• 21% of women who have had a previous preterm birth will have another one in their subsequent pregnancy. They are
two-and-a-half times more likely to have a preterm birth than a pregnant woman who has not previously had a
preterm birth.
• Preterm birth occurs in 5–10% of all birth in resource-rich countries. In recent years the incidence seems to have
increased in some countries, particularly the USA, where it was nearly 13% in 2005.
Causes
• 30% are unexplained and spontaneous
• 30% are due to multiple births (twins, triplets)
• 20-25% are associated with genital tract infection, preterm rupture of membranes, antepartum haemorrhage, cervical
incompetence and congenital uterine abnormalities
• 15-20% are elective preterm delivery due to high maternal blood pressure, fetal growth restriction, congenital
abnormalities, or medical disorders of pregnancy.
For unexplained and spontaneous preterm births, the two main risk factors are
• low socioeconomic status
• previous preterm delivery.
Question 28 Meta-analysis

Must include all published and un-published Is typically used to assess the power of a
A B
studies randomized trial
Should not include studies that did not have
C D Results are typically displayed in a forest plot
sufficient power to detect the effect of interest
E Results may be displayed in a funnel plot
Explanation
Meta-analysis & Systematic Reviews
Meta-analysis
• A statistical technique for combining the findings from independent studies and is often used to assess the clinical
effectiveness of healthcare interventions
• Meta-analysis combines data from two or more randomised control trials to provide a more precise estimate of
treatment effect, giving due weight to the size of the different studies included
• The validity of a meta-analysis depends on the quality of the systematic review on which it is based. The aim should
be to include all relevant studies, look for the presence of heterogeneity, and explore the robustness of the main
findings.
• The main requirement for a useful meta-analysis is a well-executed systematic review. If the review is unsystematic,
then the meta-analysis may provide a statistical estimate that is wrong.
Question 29 A systematic review
Cannot be undertaken if there are no randomized

A Cannot be undertaken without a meta-analysis B
trials
Should only include published peer-reviewed
C Uses methodology that reduces the effects of bias D
studies
E Should not exclude any publishes studies
Explanation
A systematic review
Systematic review
• A rigorous synthesis of all the literature on a specific question using methodology that reduces the influence of bias. A
systematic review:
• Addresses a clearly formulated question
• Uses explicit methods to identify, select and critically appraise relevant research
• Uses all relevant studies, published and unpublished
• Uses explicit methods to collect and analyse data from the studies that are included
Statistical methods (meta-analysis) may or may not be used to analyse and summarize the results of included studies
which are considered similar enough to combine
Systematic review methodology is central to meta-analysis. The objective of systematic reviews is to present a
balanced and impartial summary of the existing research, enabling decisions on effectiveness to be based on all
relevant studies of adequate quality.
The main requirement of systematic review is a complete, unbiased collection of all the original studies of acceptable
quality that examine the same therapeutic question. There are many checklists for the assessment of the quality of
systematic reviews, for example, the QUOROM statement (quality of reporting of meta-analyses).

Question 30 A funnel plot
Is used to display the results of a systematic

A B Is used to display the results of a meta-analysis
review
Is used to determine the statistical power in a
C Is used to test for publication bias D
randomized trial
E Typically has sample size on the x-axis
Explanation
Checking for publication bias
• A key step in meta-analysis is checking for publication bias, as studies that obtain negative findings are less likely to
be published than those that have positive findings
• One way of assessing the presence of publication bias is using a funnel plot.
• Funnel plots display the studies included in the meta-analysis in a plot of effect size against sample size (or another
measure of the extent to which the findings could be affected by chance).
• Smaller studies have more chance variability than larger studies so the expected picture is one of a symmetrical
inverted funnel
• An asymmetric plot suggests that the meta-analysis may have missed some trials
• Asymmetry may also occur because smaller studies tend to have larger effect
Funnel plot
• The vertical axis is some measure of the precision of the estimate of the treatment effect (such as sample size).
• The smaller the confidence interval (or the larger the sample size), the more precise the study, and the further up the
study is placed.
• Suitable measures of precision include standard error of the log of the relative risk and sample size.
• The horizontal axis measures the treatment effect. For example, the relative risk, presented on a log scale
• The point estimate from each study is then plotted
• A vertical line may be added to indicate the pooled estimate from the meta-analysis
• Less precise studies (with smaller sample size) are more affected by the play of chance, and so are more widely
scattered about the pooled estimate.
• Larger studies will be expected to be closer to the pooled estimate.
• This should produce a triangular shape, or inverted funnel

Question 1 The incidence of miscarriage in clinical pregnancies in the UK
A 1-1.2% B 1.5-2%
C 3.0 – 5.5% D 7.5 – 9.5%
E 10-15%
Explanation
MISCARRIAGE
70%
5%
lower (4%)
Question 2 Which one of the above is associated with an increased risk of ectopic pregnancy?
A High maternal age B High paternal age

C Use of progestogen-only contraception D Previous medical termination of pregnancy
E Previous caesarean section
Explanation
RISK FACTORS FOR ECTOPIC PREGNANCY
• PID
• IUCD
• Sterilisation
• Tubal surgery
• Previous ectopic
• Assisted reproduction

• Mini-pill
All current contraceptive users, including IUCD are less likely to have an ectopic pregnancy than sexually active
women not using contraception
IUCD users (except MIRENA) are 3 times more likely to have an ectopic pregnancy than users of other
contraceptives
Use of depot medroxyprogesterone acetate is associated with a lower risk of ectopic pregnancy than the mini-pill but
higher than the COCP
Question 3 With respect to factors that affect fertility
Fecundability increases with increased frequency

A Male fertility declines with age B
of sexual intercourse
Smoking has no significant effect on semen
C Alcohol intake reduces female fertility D
parameters
E Smoking has no effect on female fertility
Explanation
Factors affecting fertility
• Natural female fertility declines with age and this is more marked after the age of 35
• Fecundability is higher in fertile women having sexual intercourse than in fertile women receiving donor insemination
• The effect of age on male fertility is less clear
• Fecundability rises sharply with frequency of intercourse
• Psychological stress can affect libido and coital frequency and hence fertility
• There is inconsistent evidence about the impact of alcohol intake on female fertility
• Excessive alcohol consumption can be detrimental to semen quality but the effect is reversible and there is no
evidence of a causal association between moderate alcohol consumption and poor semen quality.
• There is a significant association between smoking and reduced fertility among female smokers
• There is an association in men between smoking and reduced semen parameters. However, the relationship between
male smoking and fertility is uncertain.
• Male and female exposure to cigarette smoke in utero is associated with reduced fertility later in life
• Women with BMI over 30 take longer to conceive, compared with women with lower BMI, even after adjusting for
other factors
• In women, weight loss of over 15% of ideal body weight is associated with menstrual
• dysfunction and secondary amenorrhoea when over 30% of body fat is lost
• Restoration of body weight may help to resume ovulation and restore fertility
• There is an association between elevated scrotal temperature and reduced semen quality, but it is uncertain whether
wearing loose-fitting underwear improves fertility.
Question 4 With respect to the uptake of contraception in women aged 16-49 years in the UK
50% of women use the combined oral The male condom is the method of contraception
A B
contraceptive pill in 10% of women
C 25% of women do not use any contraception D Sterilization is used by 15% of women
E The female condom is used by 10% of women

Explanation
Male condom 25%
IUCD 6%
Withdrawal 4%
Injection 3%
Implant 1%
Rhythm / Persona 2%
Hormonal IUS 2%
Sterilisation 6%
Question 5 The commonest sexually transmitted infection in the UK
A Gonorrhoea B Chlamydia
C Genital warts D Genital herpes
E Genital candidiasis
Explanation
Sexually transmitted infections
• The total number of STIs diagnosed per year continues to rise
• Young people aged 15-24 years are most affected by STIs. ~2/3 of new STI diagnoses in women and ½ of those
diagnosed in men were in those aged under 25.
• Rates of acute STIs were highest urban areas, particularly London.
Genital Chlamydial trachomatis
• Commonest STI diagnosed in the UK with 348.7 new cases per 100,000 population
• In 2009 there were 217, 570 new chlamydia diagnoses
• A National Chlamydia Screening Programme (NCSP) for sexually active women and men under 25 years of age has
been in operation in England since 2003 and about one in ten of those screened were found to be positive
• Untreated, 10-40 per cent of women with genital chlamydial infection will develop pelvic inflammatory disease (PID)
which could result in tubal factor infertility, ectopic pregnancy and chronic pelvic pain
Genital warts
• Caused by HPV, mainly types 6 and 11

• Commonest viral STI in the UK and second commonest STI with a gradual increase in cases since the 1970s.
• The rate of new diagnoses was 148.7 per 100,000 population, with the highest rates in women 16-19 and men aged
20-24.
• The rate of new diagnoses appears to be increasing in the over 45 age group
Genital herpes
• There were 30,126 new cases diagnosed in 2009
• The rate of new diagnoses was 49.1 per 100,000 population with the highest rates in women aged 16-19 and 20-24
• The rate of new diagnoses has increased in the over 45 age group over the last 10 years
• Changes in sexual behaviour where oral sex is becoming more common and a decreased immunity in young people
to HSV-1 have contributed to a rise in incidence
Gonorrhoea
• The overall rate of new diagnoses was 27.7 per 100,000 population, with the highest rates in men aged 20-24 and
women aged 16-19
Syphilis
• The number of new cases have increased by over 600 per cent in the last 10 years.
• Men accounted for 88 per cent of the diagnoses with ~50% of these cases were in men who have sex with men.
• The overall rate of new diagnoses was 3.8 per 100,000 population. The highest rates were in men aged 25-34 and
35-44
HIV & AIDS
• 6,630 new diagnoses of HIV in the UK in 2009
• 54 per cent of infections were acquired through heterosexual intercourse
• 68% of heterosexual infections were acquired outside the UK
• 42 per cent of infections were acquired through sex between men. This group remains most at risk of acquiring HIV
within the UK.
• There were 547 AIDS diagnoses and 516 HIV-related deaths in 2009.
With respect to the levels of evidence for the accuracy of diagnostic tests, which one is not
Question 6
true?
A Level Ib evidence is derived from level 1 studies B Level II evidence is evidence from level 2 studies
Level II evidence is evidence from systematic Level 2 studies use a blind comparison of the test
C D
reviews of level 2 studies with a validated gold standard
Level 2 studies use a sample that does not reflect
E
the population in whom the test would be applied
Explanation
Levels of evidence for accuracy of diagnostic tests
Ib: Level-1 studies

following:

Question 7 With respect to diabetes mellitus in pregnancy
The majority of pregnancies affected by diabetes Diabetes affects 0.2 – 0.5% of pregnancies in the
A B
are due to pre-existing type 2 diabetes UK
Pre-existing type 2 diabetes affects 0.1% of births Pre-existing type 1 diabetes affects 1% of births in
C D
in the UK the UK
The prevalence of type 1 diabetes is decreasing
E
in the UK
Explanation
The proportion of pregnancies complicated by diabetes that are due to pre-existing type 1
Question 8
diabetes
A 0.1-0.3% B 2-5%
C 5-7% D 10-20%
E 30-50%
Explanation

Question 9 With respect to pre-term birth
Over 75% of pre-term births occur before 28

A 1 in 20 babies are born pre-term B
weeks gestation
The majority of extremely pre-term babies are
C The incidence of pre-term birth is decreasing D
large-for-dates
20% of women who have a pre-term birth will
E have another pre-term birth in their subsequent
pregnancy
Explanation
In England and Wales
• 8% (1 in 13) of live births are born preterm
• 94% of singleton babies born extremely preterm are of very low birthweight, whereas fewer than 1% of those born at
term are
• 93% of preterm births occur after 28 weeks of gestation, but 6% occur between 22 and 27 weeks, and just under 1%
occur before 22 weeks.
• 21% of women who have had a previous preterm birth will have another one in their subsequent pregnancy. They are
two-and-a-half times more likely to have a preterm birth than a pregnant woman who has not previously had a
preterm birth.
• Preterm birth occurs in 5–10% of all birth in resource-rich countries. In recent years the incidence seems to have
increased in some countries, particularly the USA, where it was nearly 13% in 2005.
Causes
• 30% are unexplained and spontaneous
• 30% are due to multiple births (twins, triplets)
• 20-25% are associated with genital tract infection, preterm rupture of membranes, antepartum haemorrhage, cervical
incompetence and congenital uterine abnormalities
• 15-20% are elective preterm delivery due to high maternal blood pressure, fetal growth restriction, congenital
abnormalities, or medical disorders of pregnancy.
For unexplained and spontaneous preterm births, the two main risk factors are
• low socioeconomic status
• previous preterm delivery.
Question 10 Meta-analysis
Is a statistical method of combining data from Cannot be undertaken effectively without a

A B
different systematic reviews systematic review
Cannot be performed if there are no randomized
C D Should not exclude any published studies
trials
E Should not include any un-published studies
Explanation
Meta-analysis & Systematic Reviews
Meta-analysis

• A statistical technique for combining the findings from independent studies and is often used to assess the clinical
effectiveness of healthcare interventions
• Meta-analysis combines data from two or more randomised control trials to provide a more precise estimate of
treatment effect, giving due weight to the size of the different studies included
• The validity of a meta-analysis depends on the quality of the systematic review on which it is based. The aim should
be to include all relevant studies, look for the presence of heterogeneity, and explore the robustness of the main
findings.
• The main requirement for a useful meta-analysis is a well-executed systematic review. If the review is unsystematic,
then the meta-analysis may provide a statistical estimate that is wrong.

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This Copy is for Dr.

Options for Questions 1-1

A(Correct answ er: A)

Question 2 The proportion of miscarriages that occur in the first trimester

Options for Questions 2-2

A 5.0 – 10% B 15 – 20%

A(Correct answ er: E)

This Copy is for Dr. Mohamed ElHodiby

Options for Questions 3-3

A(Correct answ er: A)

Impact of maternal age

Options for Questions 4-4

A Low pre-pregnancy BMI B Feeling stressed during pregnancy

A(Correct answ er: C)

This Copy is for Dr. Mohamed ElHodiby

Options for Questions 5-5

A High maternal age B High paternal age

A(Correct answ er: C)

The stillbirth rate for twin births in the UK

0.5 per 1000 total

A(Correct answ er: D)

This Copy is for Dr. Mohamed ElHodiby

Options for Questions 6-7

A(Correct answ er: C)

Question 8 The perinatal mortality rate in the UK

Options for Questions 8-8

A(Correct answ er: D)

This Copy is for Dr. Mohamed ElHodiby

Question 9 With respect to perinatal mortality in the UK in 2008

Options for Questions 9-9

The perinatal mortality rate is 0.75 per 1000 total

A(Correct answ er: B)

This Copy is for Dr. Mohamed ElHodiby

Options for Questions 10-10

A(Correct answ er: B)

Question 11 With respect to the epidemiology of sub-fertility

Options for Questions 11-11

A(Correct answ er: C)

This Copy is for Dr. Mohamed ElHodiby

Question 12 The contraceptive option used by 1 in 4 women aged 16 – 49 years in the UK

Options for Questions 12-12

A Male condom B Female condom

A(Correct answ er: C)

Options for Questions 13-13

This Copy is for Dr. Mohamed ElHodiby

A(Correct answ er: B)

Question 14 The commonest viral sexually transmitted infection in the UK

Options for Questions 14-14

A(Correct answ er: C)

This Copy is for Dr. Mohamed ElHodiby

Evidence from well-conducted case-control

A(Correct answ er: C)

This Copy is for Dr. Mohamed ElHodiby

Options for Questions 16-16

A(Correct answ er: C)

Ib: Level-1 studies

Options for Questions 17-17

Level 3 studies typically use a validated gold

A(Correct answ er: B)

This Copy is for Dr. Mohamed ElHodiby

Ib: Level-1 studies

Question 18 The rate of pre-eclampsia in women in their first pregnancy

A(Correct answ er: B)