Obstetric Medicine Module 2

A 32-year-old woman, 2 weeks postpartum, presents to the emergency department complaining of shortness of breath, fatigue, and palpitations. She has no significant past medical history but reports that her symptoms have progressively worsened over the past week.

On examination, her heart rate is 110 bpm, blood pressure is 100/60 mmHg, and respiratory rate is 22 breaths per minute. A physical examination reveals bilateral rales at the lung bases and an S3 gallop on cardiac auscultation.

An ECG shows sinus tachycardia with no significant ST changes or Q waves.

Given the clinical scenario, which of the following is the most appropriate next step in the diagnosis of this patient’s condition?

Transthoracic echocardiography (TTE) to assess for systolic and diastolic dysfunction.

Correct Incorrect Correct answer

Initiate high-dose corticosteroids to reduce inflammation.

Correct Incorrect Correct answer

Immediate commencement of breastfeeding to improve cardiac output.

Correct Incorrect Correct answer

Prescribe an oral contraceptive pill to stabilize hormone levels.

Correct Incorrect Correct answer

Perform a lower limb venous Doppler ultrasound to rule out deep vein thrombosis.

Correct Incorrect Correct answer

A 30-year-old patient with IgA nephropathy is seen in your clinic for a routine review. She inquires about the potential risks of pregnancy.

Which of the following clinical factors is most likely to determine her risk of an adverse pregnancy outcome?

Baseline renal function

Correct Incorrect Correct answer

Presence of hypertension

Correct Incorrect Correct answer

Age at time of pregnancy

Correct Incorrect Correct answer

Level of proteinuria

Correct Incorrect Correct answer

History of previous pregnancy outcomes

Correct Incorrect Correct answer

Based on the known haematological changes that occur in pregnancy, which of the following hematological profiles is NOT consistent with normal pregnancy changes?

Diagnosis of B12 deficiency based on decreased serum B12 levels

Correct Incorrect Correct answer

Hemoglobin level of 108 mg/dL in the first trimester

Correct Incorrect Correct answer

White blood cell count of 15 (x10^9/L) in the second trimester

Correct Incorrect Correct answer

Ferritin level of 25 indicating iron insufficiency

Correct Incorrect Correct answer

Hemoglobin level of 102 mg/dL in the third trimester

Correct Incorrect Correct answer

What respiratory physiology change is most characteristic of pregnancy and contributes to reduced physiological reserves?

Increased tidal volume

Correct Incorrect Correct answer

Decreased respiratory rate

Correct Incorrect Correct answer

Decreased oxygen consumption

Correct Incorrect Correct answer

Increased functional residual capacity

Correct Incorrect Correct answer

Increased residual volume

Correct Incorrect Correct answer

Which of the following is an additional goal of asthma management in pregnancy aimed at optimizing fetal oxygenation?

Implementing "smart therapy" with combined inhaled corticosteroids (ICS) and long-acting beta agonists (LABA) as both preventer and reliever

Correct Incorrect Correct answer

Limiting the use of inhaled corticosteroids to reduce medication exposure

Correct Incorrect Correct answer

Using short-acting beta agonists (SABA) exclusively for asthma control

Correct Incorrect Correct answer

Avoiding immunizations during pregnancy to prevent exacerbations

Correct Incorrect Correct answer

Replace smoking with vaping.

Correct Incorrect Correct answer

Which of the following is a likely outcome of using an inflammation-based management strategy (measuring exhaled nitric oxide fraction [FeNO]) for asthma in pregnant women?

A 50% reduction in exacerbations requiring medical intervention.

Correct Incorrect Correct answer

No significant difference in asthma exacerbations compared to supportive care.

Correct Incorrect Correct answer

Increased risk of pneumonias during pregnancy.

Correct Incorrect Correct answer

A decreased in quality of life (QOL) measures.

Correct Incorrect Correct answer

Increased incidence of recurrent bronchiolitis or recurrent croup in infants in the first 12 months of life.

Correct Incorrect Correct answer

Which of the following statements is accurate regarding contraception methods in women with epilepsy who are on antiepileptic drugs (AEDs)?

Oral vitamin K supplementation is advised in the last 4 weeks of pregnancy for women on enzyme-inducing AEDs to mitigate oxidative degradation.

Correct Incorrect Correct answer

The progestogen-only pill (POP) and Implanon are considered effective contraceptive choices for women using enzyme-inducing AEDs.

Correct Incorrect Correct answer

Depo-Provera (a high-dose progestogen) is recommended for its immediate reversibility and lack of impact on bone health in women using enzyme-inducing AEDs.

Correct Incorrect Correct answer

Intrauterine devices (IUDs) are not recommended for women with epilepsy due to an increased risk of seizures.

Correct Incorrect Correct answer

Enzyme-inducing AEDs do not affect the efficacy of hormonal contraceptives, including the progestogen-only pill (POP) and Implanon.

Correct Incorrect Correct answer

In a 23-year-old female with Crohn’s disease who becomes pregnant, which of the following medications is most likely to result in an adverse foetal outcome?

Methotrexate

Correct Incorrect Correct answer

Prednisone

Correct Incorrect Correct answer

Azathioprine

Correct Incorrect Correct answer

Sulfasalazine

Correct Incorrect Correct answer

Mesalazine

Correct Incorrect Correct answer

A pregnant woman develops an infectious mononucleosis-like illness at 12 weeks gestation, with fever, sore throat, malaise and lymphadenopathy. She is proven serologically to have acute cytomegalovirus (CMV) infection.

What is the most likely immediate outcome for the baby?

Normal baby

Correct Incorrect Correct answer

Hepatitis

Correct Incorrect Correct answer

Microcephaly

Correct Incorrect Correct answer

Pneumonitis

Correct Incorrect Correct answer

Sensorineural deafness

Correct Incorrect Correct answer

As part of the body’s adaptation to pregnancy, which of the following parameter decreases during pregnancy?

Serum creatinine

Correct Incorrect Correct answer

Cardiac output

Correct Incorrect Correct answer

Blood volume

Correct Incorrect Correct answer

Glomerular filtration rate

Correct Incorrect Correct answer

Vessel size

Correct Incorrect Correct answer

Which of the following carries the highest risk for pre-eclampsia?

Presence of antiphospholipid antibodies

Correct Incorrect Correct answer

Nulliparity

Correct Incorrect Correct answer

Multiple pregnancy

Correct Incorrect Correct answer

Pre-existing diabetes

Correct Incorrect Correct answer

Pre-eclampsia in any previous pregnancy

Correct Incorrect Correct answer

Which of the following statement is FALSE regarding smoking and preeclampsia?

Smoking increases the risk of pre-eclampsia

Correct Incorrect Correct answer

Nicotine decreases the levels of sFLT1 in normal pregnancies

Correct Incorrect Correct answer

Nicotine decreases levels of endoglin

Correct Incorrect Correct answer

Nicotine increases levels of placental growth factor

Correct Incorrect Correct answer

Smoking is protective against pre-eclampsia

Correct Incorrect Correct answer

Which of the following is beneficial in the prevention of pre eclampsia?

Low dose aspirin

Correct Incorrect Correct answer

High dose aspirin

Correct Incorrect Correct answer

Warfarin

Correct Incorrect Correct answer

Vitamin C

Correct Incorrect Correct answer

Fish oil

Correct Incorrect Correct answer

Which of the following is the most common cause of thyrotoxicosis in women of reproductive years?

Grave's disease

Correct Incorrect Correct answer

Subacute thyroiditis

Correct Incorrect Correct answer

Factitious thyroiditis

Correct Incorrect Correct answer

Iodine induced thyrotoxicosis

Correct Incorrect Correct answer

Hashimoto's thyroiditis

Correct Incorrect Correct answer

The presence of which of the following antibody is associated with increased risk of fetal loss in pregnancy?

Anti-thyroid peroxidase Ab

Correct Incorrect Correct answer

TSH receptor antibody

Correct Incorrect Correct answer

Anti-Jo1

Correct Incorrect Correct answer

Anti-Ro

Correct Incorrect Correct answer

Anti-centromere

Correct Incorrect Correct answer

Thromboembolic events such as pulmonary embolism is most likely to occur at which stage of pregnancy?

Postpartum

Correct Incorrect Correct answer

Preconception

Correct Incorrect Correct answer

First trimester

Correct Incorrect Correct answer

Second trimester

Correct Incorrect Correct answer

Third trimester

Correct Incorrect Correct answer

Which of the following familial thrombophilia is asssociated with the highest risk of venous thromboembolism in pregnancy?

Homozygous Factor V leiden deficiency

Correct Incorrect Correct answer

Antithrombin deficiency

Correct Incorrect Correct answer

Protein C deficiency

Correct Incorrect Correct answer

Heterozygous Factor V leiden deficiency

Correct Incorrect Correct answer

Protein S deficiency

Correct Incorrect Correct answer

A 30-year-old eight-month pregnant woman, on bed rest because of pregnancy-induced hypertension, presented with acute dyspnoea and left-sided pleuritic chest pain.

Physical examination showed: temperature 37.2C, pulse 118/minute, respiratory rate 28/minute and moderate tenderness over the right calf. Foetal heart sounds are normal.

Her ECG shows sinus tachycardia. Arterial blood gases on room air are PaO2 66 mmHg, PaCO2 28 mmHg and pH of 7.51.

Her chest X-ray shows minimal shadowing at the left base with obliteration of the left costophrenic angle. A duplex scan of the legs shows a non-occlusive thrombus in the left common femoral vein. A CTPA confirms the presence of pulmonary embolism. She received treatment with therapeutic dose of low molecular weight heparin.

Which one of the following should be the next step in the management of this patient in the immediate postpartum period (considering that she will be breastfeeding her baby)?

Commence warfarin and continue for at least 6 months

Correct Incorrect Correct answer

Continue with low molecular weight heparin for life

Correct Incorrect Correct answer

Continue with low molecular weight heparin for 6 months

Correct Incorrect Correct answer

Commence warfarin and continue for at least 12 months

Correct Incorrect Correct answer

Commence aspirin

Correct Incorrect Correct answer

Which of the following is inconsistent with the normal physiological changes seen in pregnancy?

Increase in albumin during the third trimester

Correct Incorrect Correct answer

Decrease in AST and ALT

Correct Incorrect Correct answer

Increase in ALP

Correct Incorrect Correct answer

Increase in cholesterol

Correct Incorrect Correct answer

Increase in serum caeruloplasmin

Correct Incorrect Correct answer

Laura is a 29-year-old woman born in Hong Kong who is now living in New Zealand. She is 28 weeks pregnant and has recently tested positive for hepatitis B surface antigen. This is her second pregnancy. Her firstborn tested positive for HBV.

She feels entirely well.

Her hepatitis B virus (HBV) DNA level is 10⁸copies/mL. Her aspartate aminotransferase level is 29 U/L and her alanine aminotransferase level is 20 U/L.

Besides giving the baby immunoprophylaxis at the time of birth, how would you manage her HBV infection to further minimize the risk of maternal-fetal transmission?

Commence treatment with lamivudine, tenofovir, or telbivudine at 32 weeks

Correct Incorrect Correct answer

Repeat her hepatitis serology in 2 months.

Correct Incorrect Correct answer

Immediately commence treatment with lamivudine, tenofovir, or telbivudine.

Correct Incorrect Correct answer

Continue to monitor her liver functions

Correct Incorrect Correct answer

Give her Hepatitis B vaccination

Correct Incorrect Correct answer

To an infant born to a chronic Hepatitis B carrier, what is the best way to prevent vertical transmission of Hepatitis B to the baby?

Hepatitis B immune globulin at the time of birth plus three doses of the recombinant hepatitis B vaccine over the first 6 months of life

Correct Incorrect Correct answer

Hepatitis B immune globulin at the time of birth only.

Correct Incorrect Correct answer

A single Hepatitis B immune globulin at 6 months of life.

Correct Incorrect Correct answer

Lamivudine,tenovofir and telbivudine to the mother at 32 weeks gestation.

Correct Incorrect Correct answer

Lamivudine alone to the mother.

Correct Incorrect Correct answer

Which one of the following modes of transmission of hepatitis B virus (HBV) is most likely to result in chronic carrier status in the non immunised recipient?

Vertical transmission of HBV from a pregnant carrier to her newborn baby

Correct Incorrect Correct answer

A bite to a two-year-old by a chronic carrier.

Correct Incorrect Correct answer

Blood transfusion from a chronic carrier to a 60-year-old.

Correct Incorrect Correct answer

Horizontal transmission of HBV from a chronic carrier to his/her five-year-old sibling.

Correct Incorrect Correct answer

Needle-stick injury to a 21-year-old from a contaminated needle

Correct Incorrect Correct answer

In pregnant mothers who are chronic carriers of Hepatitis B, the presence of which one of the following serology carries the greatest risk of vertical transmission of Hepatitis B to the newborn infant?

HBV DNA positivity

Correct Incorrect Correct answer

HBe Antigen

Correct Incorrect Correct answer

HBsAg

Correct Incorrect Correct answer

HBcAg

Correct Incorrect Correct answer

Hbe Antibody

Correct Incorrect Correct answer

In pregnant patients, which clinical feature is most likely to be associated with acute fatty liver of pregnancy as opposed to HELLP syndrome?

Hypoglycemia

Correct Incorrect Correct answer

Raised LDH

Correct Incorrect Correct answer

Occurrence in third trimester

Correct Incorrect Correct answer

Coagulopathy

Correct Incorrect Correct answer

Raised serum transaminases

Correct Incorrect Correct answer

What is the most common cause of direct maternal death in Australia?

Amniotic fluid embolism

Correct Incorrect Correct answer

Thromboembolism

Correct Incorrect Correct answer

Hypertensive disease

Correct Incorrect Correct answer

Pituitary apoplexy

Correct Incorrect Correct answer

Postpartum hemorrhage

Correct Incorrect Correct answer

The following are associated with increased risk of thromboembolism in pregnancy except?

Decrease activity of plasminogen activator inhibitor-2 (PAI-2)

Correct Incorrect Correct answer

Increased fibrin formation

Correct Incorrect Correct answer

Increased activity of plasminogen activator inhibitor-1(PAI-1)

Correct Incorrect Correct answer

Increase coagulation factors II,VII,VIII,X.

Correct Incorrect Correct answer

Decrease fibrinolysis

Correct Incorrect Correct answer

A pregnant patient with suspected pulmonary embolism is investigated with a CT Pulmonary Angiography (CTPA).

Which of the following types of cancer might this patient be at an increased risk for in the future?

Breast cancer

Correct Incorrect Correct answer

Ovarian cancer

Correct Incorrect Correct answer

Endometrial cancer

Correct Incorrect Correct answer

Lung cancer

Correct Incorrect Correct answer

Bowel cancer

Correct Incorrect Correct answer

A pregnant patient is noted to have moderate hypertension. Treatment with anti-hypertensive will reduce the risk of all the following except?

Maternal perinatal mortality

Correct Incorrect Correct answer

Progression to severe hypertension

Correct Incorrect Correct answer

Respiratory distress in neonate

Correct Incorrect Correct answer

Induction of labour

Correct Incorrect Correct answer

Maternal stroke

Correct Incorrect Correct answer

Which of the following liver function parameter increases during normal pregnancy?

Alkaline Phosphatase

Correct Incorrect Correct answer

Aspartate Aminotransferase

Correct Incorrect Correct answer

Alanine Aminotransferase

Correct Incorrect Correct answer

Bilirubin

Correct Incorrect Correct answer

Gamma-Glutamyl Transferase

Correct Incorrect Correct answer

A 29-year-old primigravida at 29 weeks gestation presents with drowsiness and right upper quadrant pain and vomiting. Physical examination reveals poor peripheral perfusion, a pulse rate of 96/minute and blood pressure of 170/110 mmHg. There is tenderness in the right upper quadrant and brisk reflexes.

Liver function tests show:

bilirubin 14 μmol/L [2-14]
alkaline phosphatase (ALP) 200 U/L [40-130]
gamma glutamyltranspeptidase (GGT) 15 U/L [1-35]
aspartate transaminase (AST) 630 U/L [8-35]
alanine transaminase (ALT) 550 U/L [8-40]
urine dipstick 1+ proteinuria Serum creatinine is 150

Which of the following is the most appropriate intervention?

Intravenous magnesium sulphate

Correct Incorrect Correct answer

Ursodeoxycholic acid

Correct Incorrect Correct answer

Methyldopa

Correct Incorrect Correct answer

Cilazapril

Correct Incorrect Correct answer

Intravenous phenytoin

Correct Incorrect Correct answer

A 34-week pregnant patient presents to emergency with epigastric and right upper quadrant pain and nausea. Blood pressure is 140/85 mmHg.

Relevant blood work shows:

Aspartate transaminase (AST) 150 IU/L [15 – 45 IU/L]
Prothrombin Time 14 secs [11 – 15 secs] Bilirubin 25 μmol/L [14 – 22 μmol/L]
Platelets 75 x 109/L [150 – 400 x 109/L]
Haemoglobin (Hb) 90 g/L [110 – 130 g/L]

Transabdominal ultrasound reveals sludge in the gall bladder.

The most appropriate management is:

urgent delivery

Correct Incorrect Correct answer

urgent endoscopic retrograde cholangiopancreatography (ERCP) with biliary sphincterotomy.

Correct Incorrect Correct answer

antibiotics and elective cholecystectomy

Correct Incorrect Correct answer

plasma exchange

Correct Incorrect Correct answer

magnesium sulphate

Correct Incorrect Correct answer

A 34-week pregnant patient presents to emergency with epigastric and right upper quadrant pain and nausea. Blood pressure is 140/85 mmHg.

Relevant blood work shows:

Aspartate transaminase (AST) 150 IU/L [15 – 45 IU/L]
Prothrombin Time 14 secs [11 – 15 secs]
Bilirubin 25 μmol/L [14 – 22 μmol/L]
Platelets 75 x 109/L [150 – 400 x 109/L]
Haemoglobin (Hb) 90 g/L [110 – 130 g/L]
Serum creatinine and uric acid normal.
Serum glucose normal

Transabdominal ultrasound reveals sludge in the gall bladder.

What is the most likely diagnosis?

HELLP syndrome

Correct Incorrect Correct answer

Acute fatty liver of pregnancy

Correct Incorrect Correct answer

Thrombotic thrombocytopenia

Correct Incorrect Correct answer

Hyperemesis gravidarum

Correct Incorrect Correct answer

Hepatic infarction

Correct Incorrect Correct answer

A 34-week pregnant patient presents to emergency with whole body itch and jaundice.Blood pressure is 140/85 mmHg.

Relevant blood work shows:

ALP and GGT mildly elevated.
Bilirubin 25 μmol/L [14 – 22 μmol/L]
Haemoglobin (Hb) 110 g/L [110 – 130 g/L]
Serum creatinine and uric acid normal.
Serum glucose normal
Serum bile acid elevated

What is the most appropriate treatment?

Ursodeoxycholic acid

Correct Incorrect Correct answer

Delivery of baby

Correct Incorrect Correct answer

IV Magnesium sulphate

Correct Incorrect Correct answer

Plasma exchange

Correct Incorrect Correct answer

Intravenous Immunoglobulins

Correct Incorrect Correct answer

A 23-year-old woman, during her first pregnancy, has a blood pressure of 170/115 mmHg (on repeated measurements) at 32 weeks gestation. Her previous blood pressures have been 125/75 mmHg or less.

Her serum electrolytes, urea and creatinine are normal but her serum uric acid is 0.38 mmol/L [0.09-0.36].

Urinalysis shows proteinuria +++, but no evidence of blood or glucose. Liver function tests and full blood count are normal.

Which one of the following is the most appropriate initial treatment?

Nifedipine

Correct Incorrect Correct answer

Methyldopa

Correct Incorrect Correct answer

Prazosin

Correct Incorrect Correct answer

Hydralazine

Correct Incorrect Correct answer

Sodium Nitroprusside

Correct Incorrect Correct answer

A drug is described as Pregnancy category C.

What is the best description of the drug’s safety profile in this category?

Animal studies have shown adverse effect on the fetus and there are no studies in humans, but potential benefits may warrant use of the drug in pregnant women despite potential risks.

Correct Incorrect Correct answer

No evidence of risk to fetus in the first trimester of pregnancy and also in later trimesters.

Correct Incorrect Correct answer

Animal studies have shown adverse effect, but studies in pregnant women have failed to demonstrate a risk to the fetus in any trimester.

Correct Incorrect Correct answer

Positive evidence of human fetal risk but potential benefits may warrant use of the drug in pregnant women despite potential risks.

Correct Incorrect Correct answer

Studies have demonstrated positive evidence of human fetal risk and the risks involved in use of the drug in pregnant women clearly outweigh potential benefits.

Correct Incorrect Correct answer

Which of the following intervention does not have any therapeutic role in the management of HELLP syndrome?

Dexamethasone

Correct Incorrect Correct answer

Platelet transfusion

Correct Incorrect Correct answer

Delivery of baby

Correct Incorrect Correct answer

Opioids

Correct Incorrect Correct answer

Labetalol.

Correct Incorrect Correct answer

A 29-year-old woman with a history of rheumatoid arthritis is planning for pregnancy. She has been in remission for the past year while on etanercept.

During her pre-conception counseling, she inquires about the safety of her current treatment during pregnancy.

Which of the following is the most appropriate advice regarding her treatment with etanercept during pregnancy?

Continue etanercept throughout pregnancy as it does not significantly cross the placenta.

Correct Incorrect Correct answer

Switch to certolizumab due to its better safety profile in pregnancy.

Correct Incorrect Correct answer

Discontinue etanercept immediately to prevent fetal risks.

Correct Incorrect Correct answer

Switch to a conventional synthetic DMARD with a safer profile in pregnancy.

Correct Incorrect Correct answer

Transition to high-dose steroids for the duration of the pregnancy.

Correct Incorrect Correct answer

A 34-year-old pregnant woman with a pre-pregnancy BMI of 35 kg/m^2 attends her first antenatal clinic. She is concerned about the complications her obesity may cause during pregnancy.

Based on the association of maternal obesity with various adverse pregnancy outcomes, which of the following complication has the highest chance of occurring during the course of her pregnancy compared to women with a normal BMI?

Gestational diabetes

Correct Incorrect Correct answer

Neural tube defects

Correct Incorrect Correct answer

Extremely low birth weight

Correct Incorrect Correct answer

Hypertensive disorders of pregnancy

Correct Incorrect Correct answer

Large for gestational age infant

Correct Incorrect Correct answer

A 28-year-old pregnant woman is diagnosed with obstetric cholestasis (OC) at 32 weeks of gestation. She is concerned about the possible outcomes of her pregnancy due to this condition.

Based on the known consequences of obstetric cholestasis, which of the following statements is most accurate regarding the risks associated with OC?

Obstetric cholestasis is associated with an increased risk of preeclampsia (PET), gestational diabetes mellitus (GDM), and metabolic syndrome in the mother.

Correct Incorrect Correct answer

The risk of intrauterine and perinatal death is significantly increased in all women with OC, regardless of their peak bile acid levels.

Correct Incorrect Correct answer

The use of cardiotocography (CTG) and ultrasound (US) can reliably predict the risk of obstetric cholestasis-related complications.

Correct Incorrect Correct answer

Vitamin K supplementation is unnecessary in the management of obstetric cholestasis as it does not affect the risk of postpartum hemorrhage (PPH).

Correct Incorrect Correct answer

The risk of intrauterine death and perinatal death significantly increases only in women whose peak bile acid levels exceed 40 umol/L.

Correct Incorrect Correct answer

A 32-year-old woman is admitted with symptoms suggestive of preeclampsia at 36 weeks of gestation.

Based on the understanding of the pathophysiological mechanisms underlying preeclampsia, it can be classified into early-onset preeclampsia (EOPE) and late-onset preeclampsia (LOPE).

Which of the following statements correctly describes the distinction between EOPE and LOPE?

EOPE is triggered by dysfunctional perfusion of the placenta due to impaired placentation, whereas LOPE results from a mismatch between maternal perfusion and the metabolic demands of the placenta and fetus.

Correct Incorrect Correct answer

EOPE is primarily caused by maternal predisposition to inflammation, high BMI, and high arterial pressure, whereas LOPE is triggered by dysfunctional placental perfusion due to impaired placentation.

Correct Incorrect Correct answer

Both EOPE and LOPE are triggered by identical pathophysiological mechanisms, including syncytiotrophoblast oxidative stress and placental hypoxia, without any distinctive causes.

Correct Incorrect Correct answer

LOPE is exclusively related to maternal genetic factors, while EOPE results from environmental factors and maternal lifestyle choices.

Correct Incorrect Correct answer

EOPE and LOPE can be differentiated solely by the gestational age at onset, with no underlying pathophysiological distinctions.

Correct Incorrect Correct answer

Average score
Your score

Obstetric Medicine Module 2

Quiz Summary

Information

Results

Results

Categories

1. Question

2. Question

3. Question

4. Question

5. Question

6. Question

7. Question

8. Question

9. Question

10. Question

11. Question

12. Question

13. Question

14. Question

15. Question

16. Question

17. Question

18. Question

19. Question

20. Question

21. Question

22. Question

23. Question

24. Question

25. Question

26. Question

27. Question

28. Question

29. Question

30. Question

31. Question

32. Question

33. Question

34. Question

35. Question

36. Question

37. Question

38. Question

39. Question

40. Question