Monday, 26 June 2017

Tutorial 26th. June 2017

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26 June 2017.

26
SBA. Progestogen-only implants
27
EMQ. Anatomy of fetal skull and maternal pelvis
28
EMQ. Early pregnancy: diagnoses to exclude
29
EMQ. Early pregnancy: management.

26.   EMQ. Progestogen-only implants.
Progestogen-only Implants.
Abbreviations.
ENG:  etonorgestrel
HFW: hormone-free week
LNG:   levonorgestrel
Question 1.
Lead-in
Pick the best option from the list below in relation to the hormone in Nexplanon.
Option List

  1.  
68 mg. ENG

  1.  
100 mg. ENG

  1.  
100 mg. LNG

  1.  
150 mg. LNG

  1.  
50 mg. ENG + 100 mg. LVG
Question 2.
Lead-in
How does Nexplanon act as a contraceptive?
         i.            mainly by inducing anovulation
       ii.            mainly by altering cervical mucus to the detriment of sperm transport
     iii.            mainly by thinning the endometrium, preventing implantation
     iv.            mainly by inducing loss of libido
Choose the best option from the list below.
Option List

  1.  
I

  1.  
I + II

  1.  
I + III

  1.  
II + III

  1.  
III + IV
Question 3.
Lead-in
What is the age range, if any, for which Nexplanon is licensed in the UK?
Option List

  1.  
15 – 50 years

  1.  
18 – 40 years

  1.  
18 – 45 years

  1.  
20 – 50 years

  1.  
None of the above.
Question 4.
Lead-in
A woman who is not in the licensed age range requests a Nexplanon. How should the advising doctor proceed?
Option List

  1.  
Advise her about alternative licensed contraceptive methods, but decline to insert Nexplanon

  1.  
Advise her about alternative licensed contraceptive methods and insert Nexplanon

  1.  
Fit her with a LNGIUS

  1.  
Refer her to a colleague who fits anyone who asks with a Nexplanon

  1.  
None of the above
Question 5.
Lead-in
Which, if any, of the following statements best describes the pregnancy rate for women using Nexplanon are true?
Option List

  1.  
The pregnancy rate is < 1 per 1,000 women during 3 years of use

  1.  
The pregnancy rate is < 5 per 1,000 women during 3 years of use

  1.  
The pregnancy rate is < 10  per 1,000 women during 3 years of use

  1.  
The pregnancy rate is 10-20 per 1,000 women during 3 years of use

  1.  
None of the above
Question 6.
Lead-in
Which, if any, other implants are licensed in the UK?
Option List

  1.  
Implanon

  1.  
Norplant

  1.  
Norplant-2

  1.  
Jadelle

  1.  
None of the above
Question 7.
Lead-in
What are the main differences between Nexplanon and Implanon?
Pick the most suitable answer from the list below.
Option List

  1.  
The dosage was increased from 60 to 68 mg. etonorgestrel

  1.  
The dosage was increased from 150 – 175 mg. levonorgestrel

  1.  
Barium sulphate was added to Nexplanon to make it radio-opaque

  1.  
The number of rods was reduced to 2

  1.  
None of the above
Question 8.
Lead-in
What problems is the new applicator designed to minimise?
        I.            non-insertion
      II.            deep insertion
    III.            difficulty with one-handed insertion
    IV.            difficulty with left-handed insertion
      V.            difficulty with insertion in very thin women.
Option List

  1.  
I + II + III + IV

  1.  
I + II + III + IV + V

  1.  
II + III

  1.  
II + III + IV

  1.  
II + III + IV + V

Question 9.
Lead-in
How long is Nexplanon licensed for?
Option List

  1.  
1 year

  1.  
2 years

  1.  
3 years

  1.  
5 years

  1.  
10 years
Question 10.
Lead-in
What does NICE recommend that patients be told about bleeding patterns with Nexplanon?
        I.            menstrual bleeding may cease
      II.            menstrual bleeding may become prolonged
    III.            bleeding may become more frequent
    IV.            menstrual bleeding may become less frequent
      V.            intermenstrual bleeding can be a problem in the first 6 months
Option List

I + II + III

I + II + III + IV

II + III + IV + V

I + III + IV

I + III + IV + V
Question 11.
Lead-in
What information should women be given about the effect of Nexplanon on pain?
Option List

  1.  
Dysmenorrhoea may increase

  1.  
Dysmenorrhoea may decrease

  1.  
Mittelschmerz is likely to cease

  1.  
Pain due to endometriosis is likely to decrease

  1.  
Dyspareunia is likely to be alleviated
Question 12.
Lead-in
A 25-year old nulliparous woman has been found to have a few spots of endometriosis in the pouch of Douglas at laparoscopy for pelvic pain. She wishes to avoid pregnancy for 5 years but then wishes to have two children. She has read an article suggesting that a progesterone-only implant provides high levels of contraceptive efficacy and good results in suppressing endometriosis. What advice will you give?
Option List

  1.  
Recommend a low-dose COC and tricycling as the best means of suppressing endometriosis plus providing effective contraception

  1.  
Recommend a low-dose COC taken continuously as the best means of suppressing endometriosis plus providing effective contraception

  1.  
Recommend Nexplanon as the best means of suppressing endometriosis plus providing effective contraception

  1.  
Recommend Depot-Provera as the best means of suppressing endometriosis plus providing effective contraception

  1.  
None of the above
Question 13.
Lead-in
When can a Nexplanon be inserted with no need for additional contraception  in a woman with regular menstrual cycles and no contraindication to its use?
Option List

  1.  
Up to and including day 3 of menstruation

  1.  
Up to and including day 5 of menstruation

  1.  
Up to and including day 7 of menstruation

  1.  
Never

  1.  
None of the above
Question 14.
Lead-in
A healthy 25 year-old-woman is recovering well from a normal delivery. She is not breastfeeding and wishes to start Nexplanon.
Option List
Pick the best statement from the list below.

  1.  
No additional contraception is needed if Nexplanon is inserted by day 7

  1.  
No additional contraception is needed if Nexplanon is inserted by day 14

  1.  
No additional contraception is needed if Nexplanon is inserted by day 21

  1.  
No additional contraception is needed if Nexplanon is inserted by day 28

  1.  
No additional contraception is needed if Nexplanon is inserted by day 42
Question 15.
Lead-in
A healthy 20-year-old woman wishes to switch from a COC to Nexplanon. What rules apply to the need for additional contraception?
I
If insertion takes place on day 1 of the HFW, no additional contraception is needed.
II
If insertion takes place on day 5 of the HFW, additional contraception is needed for 7 days.
III
If insertion takes place in week 2 after the HFW, no additional contraception is needed.
IV
If insertion takes place in week 3 after the HFW, no additional contraception is needed.
Option List
A
I
B
I + II
C
I + II + III
D
II + III + IV
E
I + II + III + IV
Question 16.
Lead-in
I
Women switching from a POP to Nexplanon should be advised that additional contraception is required for 7 days.
II
Women switching from a POP to Nexplanon should be advised that additional contraception is not required.
III
Women switching from a LNGIUS to Nexplanon should be advised that additional contraception is required for 7 days.
IV
Women switching from a LNGIUS to Nexplanon, should be advised that additional contraception is not required.
Option List
A
I + III
B
I + IV
C
II + III
D
II + IV
E
none of the above

27.   EMQ.  Anatomy of fetal skull and maternal pelvis.
This is a new answer. Please let me know if you find any errors, typos or bits that are not clear.
Scenario 1.                
How many bones make up the vault of the skull?
Option list.
A.       
3
B.       
5
C.       
6
D.       
7
E.        
8
Scenario 2.                
What is the origin of the word “bregma”?
Option list.
A.       
the Greek word meaning “arrow”
B.       
the Greek word meaning “front of the head”
C.       
the Greek word meaning “top of the head”
D.       
the Greek word meaning “where lines intersect”
E.        
none of the above
Scenario 3.                
What is the origin of the word “lambdoid”?
Option list.
A.       
it is derived from “lambda”, the 11th. letter of the Greek alphabet, with the symbol “λ”
B.       
it is derived from the shape of the rear end of a newborn lamb, with legs apart for balance in the shape of an inverted “V”
C.       
it derives from the Norse noun “lam” meaning to hit
Scenario 4.                
What is the origin of the word “sagittal”?
Option list.
A.       
it derives from the Latin verb “sagire” meaning to be wise
B.       
it derives from the Latin noun “sagitta” meaning “arrow”
C.       
it derives from the Latin adjective “sagitta” meaning “pointing north”
D.       
it derives from the Latin adjective “sagitta” meaning “lacking tension”
Scenario 5.                
What is the meaning of the word “coronal”.
Option list.
A.       
it is the 11th. letter of the Greek alphabet
B.       
it derives from the Latin “corona” meaning “crown”.
C.       
it derives from the sun’s corona, meaning equator
Scenario 6.                
What is the definition of “vertex”?
Option list.
A.       
the most prominent part of the occiput
B.       
the area around the posterior fontanelle
C.       
the area bounded by the anterior fontanelle and the posterior fontanelle
D.       
the area bounded by the anterior & posterior fontanelles and the parietal bones
E.        
the area bounded by the anterior & posterior fontanelles and the parietal eminences
F.        
the area bounded by the anterior & posterior fontanelles and the parietal cardinals
Scenario 7.                
What is the definition of the anterior fontanelle?
Option list.
A.       
the anterior end of the sagittal suture
B.       
the area where the sagittal and coronal sutures meet
C.       
the area between the frontal and parietal bones
D.       
the posterior end of the sagittal suture
E.        
the area between the parietal bones and the occiput
Scenario 8.                
What is the definition of the posterior fontanelle?
Option list.
A.       
the anterior end of the sagittal suture
B.       
the area where the sagittal and lambda sutures meet
C.       
the area between the frontal and parietal bones
D.       
the posterior end of the sagittal suture
E.        
the area between the parietal bones and the occiput
Scenario 9.                
How many other fontanelles are there?
A.       
0
B.       
2
C.       
3
D.       
4
E.        
6
Scenario 10.            
What is the falx cerebri?
Option list.
A.       
an area of dura mater at the back of the skull like a roof over the cerebellum
B.       
is an artefact on ultrasound suggesting the presence of cerebral tissue where there is none
C.       
is the horizontal fibrous platform on which the cerebellum rests
D.       
is a crescent-shaped fold of dura mater separating the cerebral hemispheres
Scenario 11.            
What is the importance of the falx cerebri in relation to delivery, particularly breech delivery?
Option list.
A.       
the falx cerebri is inserted into the tentorium cerebelli and traction on the base of the skull may lead to tentorial tears and intracranial bleeding
B.       
the falx cerebri is inserted into the bone of base of the skull and traction on the base of the skull may lead to tears of the falx and intracranial bleeding
C.       
the falx cerebri is inserted into the tentorium cerebelli and traction on the base of the skull may lead to tentorial tears leaving the cerebellum unsupported and liable to trauma
Scenario 12.            
What diameter presents to the pelvis with vertex presentation?
Option list.
A.       
suboccipito-bregmatic
B.       
suboccipito-frontal
C.       
occipito-frontal
D.       
mento-vertical
E.        
submento-bregmatic
Scenario 13.            
What diameter presents to the pelvis with typical occipito-posterior position?
Option list.
A.       
suboccipito-bregmatic
B.       
suboccipito-frontal
C.       
occipito-frontal
D.       
mento-vertical
E.        
submento-bregmatic
Scenario 14.            
What diameter presents to the pelvis with brow presentation?
Option list.
A.       
suboccipito-bregmatic
B.       
suboccipito-frontal
C.       
occipito-frontal
D.       
mento-vertical
E.        
submento-bregmatic
Scenario 15.            
What diameter presents to the pelvis with mento-anterior face presentation?
Option list.
A.       
suboccipito-bregmatic
B.       
suboccipito-frontal
C.       
occipito-frontal
D.       
mento-vertical
E.        
submento-bregmatic
Scenario 16.            
What diameter presents to the pelvis with mento-posterior face presentation?
Option list.
A.       
suboccipito-bregmatic
B.       
suboccipito-frontal
C.       
occipito-frontal
D.       
mento-vertical
E.        
submento-bregmatic
Scenario 17.            
What is the average length of the suboccipito-bregmatic diameter in a term baby?
Option list.
A.       
  9.0 cm.
B.       
  9.5 cm.
C.       
10.0 cm.
D.       
10.5 cm.
E.        
11.0 cm.
F.        
11.5 cm.
G.       
12.0 cm.
H.       
12.5 cm.
I.         
13.0 cm.
J.         
13.5 cm.
K.        
14.0 cm.
Scenario 18.            
What is the average length of the suboccipito-frontal diameter in a term baby?
Option list.
A.       
  9.0 cm.
B.       
  9.5 cm.
C.       
10.0 cm.
D.       
10.5 cm.
E.        
11.0 cm.
F.        
11.5 cm.
G.       
12.0 cm.
H.       
12.5 cm.
I.         
13.0 cm.
J.         
13.5 cm.
K.        
14.0 cm.
Scenario 19.            
What is the average length of the occipito-frontal diameter in a term baby?
Option list.
A.       
  9.0 cm.
B.       
  9.5 cm.
C.       
10.0 cm.
D.       
10.5 cm.
E.        
11.0 cm.
F.        
11.5 cm.
G.       
12.0 cm.
H.       
12.5 cm.
I.         
13.0 cm.
J.         
13.5 cm.
K.        
14.0 cm.
Scenario 20.            
What is the average length of the mento-vertical diameter in a term baby?
Option list.
A.       
  9.0 cm.
B.       
  9.5 cm.
C.       
10.0 cm.
D.       
10.5 cm.
E.        
11.0 cm.
F.        
11.5 cm.
G.       
12.0 cm.
H.       
12.5 cm.
I.         
13.0 cm.
J.         
13.5 cm.
K.        
14.0 cm.
Scenario 21.            
What is the average length of the submento-bregmatic diameter in a term baby?
Option list.
A.       
  9.0 cm.
B.       
  9.5 cm.
C.       
10.0 cm.
D.       
10.5 cm.
E.        
11.0 cm.
F.        
11.5 cm.
G.       
12.0 cm.
H.       
12.5 cm.
I.         
13.0 cm.
J.         
13.5 cm.
K.        
14.0 cm.

28.   EMQ. Early pregnancy complications. Diagnoses to exclude.
Lead-in.
The following scenarios relate to early pregnancy.
For each, select the diagnosis you most want to exclude.
Pick one option from the option list.
Each option can be used once, more than once or not at all.
Option list.
A.           Complete miscarriage.
B.           Incomplete miscarriage.
C.           Missed miscarriage.
D.          Pregnancy in a uterine horn.
E.           Ectopic pregnancy.
F.           OHSS.
G.          Ovarian torsion.
H.          Ovarian cyst accident.
I.            Hydatidiform mole.
J.            Listeriosis.
K.           Toxoplasmosis.
L.           Crohn’s disease
M.         Ulcerative colitis.
N.          Duodenal ulceration.
O.          Pulmonary embolism.
P.           Pneumothorax.
Q.          Coronary thrombosis.
R.           None of the above.
Scenario 1.
A 35-year-old primigravida is seen in the EPU with vaginal bleeding and severe left iliac fossa pain. The pregnancy occurred after four cycles of IVF and embryo transfer was performed six weeks ago. Her β-hCG is >1,000 iu/l. An ultrasound scan showed an intra-uterine pregnancy of an appropriate size for the gestation. Normal fetal heart activity was noted. No adnexal masses were seen.
Scenario 2.
A 25-year-old woman with known PCOS is seen in the early pregnancy unit after an episode of slight vaginal bleeding. Her LMP was 10 weeks ago. An ultrasound scan shows an intra-uterine pregnancy with CRL of 6 mm. No fetal heart activity is seen.
Scenario 3.
A GP phones for advice. She is conducting her morning surgery. A nulliparous woman at 6 weeks’ gestation has returned from France where she has enjoyed the local food, particularly unpasteurised soft cheese and pork meats. She has presented with diarrhoea and mild abdominal pain. A β-hCG is 25 iu/l. She is concerned about listeriosis and toxoplasmosis, about which she has read.
Scenario 4.
A 30-year-old parous woman attends the EPU with vaginal bleeding and lower abdominal pain. An ultrasound scan shows a 30 mm. intra-uterine sac but no evidence of fetal heart activity.
Scenario 5.
 A 45-year-old para 6 is admitted to the A&E department with 6 weeks’ amenorrhoea. A β-hCG is positive. She complains of retrosternal pain and has a history of heartburn and acid reflux. Her BMI is 30. She smokes 40 cigarettes daily and has COAD.

29.   EMQ. Early pregnancy complications. Management.
Lead-in.
The following scenarios relate to early pregnancy. For each, select the most appropriate answer from the option list.
Each option can be used once, more than once or not at all.
Option List.
A.          Admit as an emergency case.
B.           Counsel and arrange TVS in 1 week.
C.           Counsel and arrange TV colour Doppler scan.
D.          Counsel re expectant management.
E.           Explain diagnosis and counsel re MEUC and SEUC.
F.           Explain diagnosis and counsel re expectant management and MEUC and SEUC.
G.          Explain diagnosis and counsel re expectant management, MEUC and SEUC and refer to the EPU.
H.          Explain diagnosis and counsel re treatment options with accent on the relative merits of SEUC and refer to the EPU.
I.            Explain diagnosis and counsel re treatment options with accent on the relative merits of MEUC and refer to the EPU.
J.            Explain diagnosis and refer to the EPU for PUL protocol.
K.           Explain diagnosis and refer to the EPU for PUV protocol.
L.           Manage as ectopic pregnancy until proven otherwise.
M.         Arrange progesterone assay.
N.          Arrange AFC.
O.          Arrange AMH assay.
P.           Arrange serial hCG monitoring for 48 hours.
Q.          Administer anti-D immunoglobulin.
R.           Administer ergometrine 0.5 mg i.m.
S.           Prescribe mifepristone.
T.           Prescribe misoprostol for vaginal use.
U.          Continue with routine booking.
V.          None of the above.
Scenario 1.
A nulliparous woman attends the booking clinic at 8 weeks’ gestation. An ultrasound scan shows a missed miscarriage of a size commensurate with the gestation. What will be your management?
Scenario 2.
A nulliparous woman attends the booking clinic at 8 weeks’ gestation. An ultrasound scan shows a missed miscarriage of a size commensurate with the gestation. She has had two previous pregnancies; both resulted in 1st. trimester miscarriage. What will be your management?
Scenario 3.
A primigravid woman attends the A&E department with abdominal pain and vaginal bleeding. A home pregnancy test was +ve 1 week ago; the date of the LMP is uncertain. What will be your management?
Scenario 4.
A 40-year old woman is pregnant for the first time. Her periods have been erratic for 12 months and she has occasional hot flushes. She attends the A&E department with abdominal pain and vaginal bleeding. The bleeding is slight and her condition is good. An hCG is +ve and a TVS shows an incomplete miscarriage. What will be your management?
Scenario 5.
A 35-year-old woman has had two normal pregnancies. She attends the booking clinic after an unplanned conception. Her hCG is +ve. A TVS shows endometrial thickening but no evidence of intra-uterine pregnancy. No pelvic abnormality is seen. What will be your management?
Scenario 6.
A 35-year-old woman has had two normal pregnancies. She attends the booking clinic after an unplanned conception. Her hCG is +ve. A TVS shows a 15 mm. intra-uterine sac, but no fetus or yolk sac. What will be your management?
Scenario 7.
A 35-year-old woman has had two normal pregnancies. She attends the booking clinic after an unplanned conception. Her hCG is +ve. A TVS shows a 30 mm. intra-uterine sac, but no fetus. What will be your management?
Scenario 8.
A 35-year-old woman has had two normal pregnancies. She attends the booking clinic after an unplanned conception. Her hCG is +ve. A TVS shows an intra-uterine fetus with crown rump length of 5 mm., but no evidence of fetal heart activity. What will be your management?
Scenario 9.
A 35-year-old woman has had two normal pregnancies. She attends the booking clinic after an unplanned conception. Her hCG is +ve. A TVS shows an intra-uterine fetus with crown rump length of 6 mm. Fetal heart activity is seen. What will be your management?
Scenario 10.
A 35-year-old woman attends the A&E department at 6 weeks’ gestation with pain and bleeding. She became pregnant after IVF. An ultrasound scan shows a viable intrauterine pregnancy of a size compatible with the gestation. What will be your management?