Thursday, 21 July 2016

Tutorial 21st; July 2016

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21 July 2016.

39
EMQ. MBRRACE
40
SBA. Recurrent miscarriage
41
EMQ. Androgen insensitivity syndrome
42
SBA. Classification of urgency of C section
43
EMQ. APH

39.   EMQ. MBRRACE.
Lead-in.
The following scenarios relate to MBRRACE.
Pick one option from the option list.
Each option can be used once, more than once or not at all.
Option list.
There is none, to make things more testing.
Scenario 1.      What is the meaning of the acronym MBRRACE-UK”?
Scenario 2.      Which organisation does it replace?
Scenario 3.      How does it differ structurally from its predecessor?
Scenario 3.      How will the format of its reports differ from those of its predecessor?
Scenario 5.      When was MBRRACE’s first Report published?
Scenario 6.      What geographical innovation was included in its first Report?
Scenario 7.      What alterations were made to the timings of maternal death to be considered in its Reports?
Scenario 8.      What was the latest MMR reported by MBRRACE?
Scenario 9.      How did this compare with the final MMR reported by CMACE?
Scenario 10.   Which topics were reviewed in detail in the first MBRRACE Report?
Scenario 11.   Which topics were reviewed in detail in the second Report in 2015?
Scenario 12.   Which topics will be reviewed in detail in the third Report in 2016?
Scenario 13.   What is the definition of a maternal death?
Scenario 14.   What is the definition of a direct maternal death?
Scenario 15.   What is the definition of indirect maternal death?
Scenario 16.   What was the leading direct cause of death in the first Report?
Scenario 17.   What was the leading indirect cause of death in the first Report?
Scenario 18.   What were the 5 top causes of direct maternal death in the triennium 2011 – 2013?
Scenario 19.   What observation was made in the first Report about deaths due to hypertensive diseases?
Scenario 20.   Which condition was linked to 1 in 11 maternal deaths in the first Report in 2014?
Scenario 21.   What key messages were singled out in the first Report?
Scenario 22.   What key messages were singled out in the second Report in 2015?
Scenario 23.   What is the definition of the maternal mortality rate?
Scenario 24.   What is the definition of a “maternity”?
Scenario 25.   What is the definition of a live birth?
Scenario 26.   What is the definition of a stillbirth?
Scenario 27.   What is the definition of the maternal mortality ratio?

40.   SBA. Recurrent miscarriage.
This question and answer are derived from a question written by Selvambigai Raman.
Abbreviations.
EPU:              dedicated early pregnancy assessment unit.
PIGD:            pre-implantation genetic diagnosis.
PIGS:             pre-implantation genetic screening.
RM:               recurrent miscarriage.
TORCH:         Toxoplasmosis, rubella, cytomegalovirus & herpes. (Other definitions include HIV, syphilis and other infections.) Fortunately, TORCH screening is out-of-date, exact definitions are not important, though I’d stick with the first if asked.
UA:                uterine anomaly.
Question 1.
Lead-in
In relation to miscarriage, which, if any, of the following statements are correct?
  1. the term “spontaneous miscarriage” is really stupid
  2. most miscarriages are genetic in causation.
  3. most women who miscarry do not get a diagnosis of causation
  4. the majority of women have significant levels of psychological distress after miscarriage.
  5. counselling is of significant benefit in reducing levels of psychological distress after miscarriage.
Option List
A.       
i + ii
B.       
i + ii + iii
C.       
i + ii + iii + iv
D.       
i + ii + iii + v
E.        
i + ii + iii + iv + v
Question 2.
Lead-in
Which of the following statements are true.
  1. miscarriage occurs in 11% of women with age 20-24 years
  2. miscarriage occurs in 25% of women with age 35-39 years
  3. miscarriage occurs in > 90% of mothers with age ≥ 45 years
  4. recurrent miscarriage affects about 1% of couples
  5. recurrent miscarriage affects about 5% of couples
Option List
A.       
i + ii
B.       
i + iii
C.       
i + ii + iv
D.       
i + iii + v
E.        
i + ii + iii + iv
Question 3.
Lead-in
What figure is usually given for the overall incidence of miscarriage?
Option List
A.       
< 10 %
B.       
10 - 20%
C.       
20 - 25%
D.       
25 – 30 %
E.        
>30%
Question 4.
Lead-in
A healthy, 26-year-old, woman attends the booking clinic at 6 weeks in her first pregnancy. A pregnancy test is +ve. Her best friend recently had an early miscarriage and she is concerned about her risk. What risk will you quote?
Option List
A.       
≤ 5%
B.       
5 – 10%
C.       
10 – 15%
D.       
15 – 20%
E.        
≥ 20%
Question 5.
Lead-in
The same healthy woman attends the ANC at 8 weeks for a dating scan. Before she has the scan she asks you what her risk is now. She has had no abnormal symptoms. What risk will you quote?
Option List
A.       
≤ 5%
B.       
5 – 10%
C.       
10 – 15%
D.       
15 – 20%
E.        
≥ 20%
Question 6.
Lead-in
The same healthy, nulliparous woman comes back to see you after the scan. The scan is normal and shows a viable fetus. She asks what her risk is now. What risk will you quote?
Option List

  1.  
≤ 5%

  1.  
5 – 10%

  1.  
10 – 15%

  1.  
15 – 20%

  1.  
≥ 20%
Question 7.
Lead-in
Pick the best option from the list below for the definition of RM.
Option List

  1.  
two or more miscarriages
B.
two or more miscarriages in healthy women
C.
three or more miscarriages
D.
three or more miscarriages in women with no children
E.
none of the above.
Question 8.
Lead-in
The following are possible causes of RM except for one. Pick the best option for the exception.
Option List

  1.  
increased maternal age

  1.  
maternal cigarette smoking

  1.  
maternal alcohol consumption

  1.  
exposure to anaesthetic gases

  1.  
exposure to emissions from video display terminals
 Question 9.
Lead-in
A woman presents to antenatal clinic for booking at 6 weeks. She has a history of 3 RMs with no explanation found after full investigation. What is her risk of miscarriage in this pregnancy?
Option List
A.       
≤ 10%
B.       
   20%
C.       
   25%
D.       
   50%
E.        
   75%
Question 10.
Lead-in
4) A 35-year-old woman with a history of 3 RMs presents to you for advice regarding the risk of miscarriage if she conceives. Pick the best option to describe her risk from the list below.
Option List
A.       
20%
B.       
30%
C.       
40%
D.       
50%
E.        
55%
Question11.
Lead-in
The following statement relates to women with arcuate uteri.
There is evidence to suggest that women with arcuate uteri:
                i.     tend to miscarry more in first trimester
              ii.     tend to miscarry more in second trimester
            iii.     have no increased risk of miscarriage
            iv.     are at increased risk of cephalo-pelvic disproportion
              v.     are at increased risk of Caesarean section
Pick the best option from the list below.
Option List
A.       
i
B.       
i + v
C.       
ii + iv
D.       
ii + v
E.        
iii + v
Question 12.
Lead-in
With regards to EPUs, which of the following statements, if any, are true.
         i.            all women with pain + bleeding in early pregnancy can self-refer to an EPU
       ii.            all women with pain + bleeding in early pregnancy should be seen by a health professional before referral to an EPU
     iii.            women with a history of ectopic pregnancy, molar pregnancy or recurrent miscarriage should be able to self-refer to an EPU
     iv.            women with a history of puerperal psychosis should be able to self-refer to an EPU
Option List
A.       
i
B.       
ii
C.       
iii
D.       
iv
E.        
iii + iv
Question 13.
Lead-in
Which, if any, of the following investigations should be done for a couple with 1st trimester RM?
         i.            APS screen
       ii.            Fragile X syndrome screen
     iii.            HbA1c
     iv.            hysterosalpingogram
       v.            inherited thrombophilia screen
     vi.            karyotyping
    vii.            NK cells in peripheral blood
  viii.            thyroid function tests
     ix.            TORCH screen
Option List
A.       
i
B.       
i +  v
C.       
i + ii + v + vi + viii + ix
D.       
i + iii + iv + v + vi + vii + viii + ix
E.        
all of the above except vii
Question 14.
Lead-in
Which, if any of the following treatments should be offered to women with RM and evidence of APS?
Option List
         i.             
low-dose aspirin + clopidogrel
       ii.             
low-dose aspirin + LMWH
     iii.             
low-dose aspirin + LMWH + low-dose corticosteroids
     iv.             
low-dose aspirin + unfractionated heparin
       v.             
low-dose aspirin  + unfractionated heparin + low-dose corticosteroids
Question 15.
Lead-in
Which, if any, of the following treatments are of proven benefit in improving outcomes in unexplained RM?
         i.            cervical cerclage
       ii.            hCG
     iii.            leptin
     iv.            LH
       v.            metformin
     vi.            rectal or vaginal progesterone
    vii.            supportive therapy in a dedicated EPU
  viii.            PIGS
Option List
A.       
i + ii
B.       
i + vi + vii
C.       
ii + vi + vii + vii
D.       
 vii
E.        
none of the above
Question 16 .
Lead-in
With regard to the role of PIGS in the management of women with unexplained RM, which, if any, of the following statements are true.
         i.            PIGS is of proven benefit in unexplained RM
       ii.            PIGS is regulated by the HFEA
     iii.            PIGD and PIGS are different names for the same process
Option List
A.       
i
B.       
ii
C.       
i + ii
D.       
i + ii + iii
E.        
none of the above
Question 17.
Lead-in
Pick the most appropriate option from the list below about the risk of miscarriage in women with PCOS and a history of RM who conceive spontaneously.
Option List
A.       
increased serum LH levels predict an increased risk of miscarriage
B.       
Increased testosterone levels predict an increased risk of miscarriage
C.       
Decreased androgen levels predict an increased risk of miscarriage
D.       
Typical PCOS ovarian morphology predicts an increased risk of miscarriage
E.        
Hyperinsulinaemia predicts an increased risk of miscarriage

41.   EMQ. Androgen insensitivity syndrome.
Abbreviations.
AIS:  androgen insensitivity syndrome
Question 1.
Lead-in
What is the estimated prevalence of AIS?
Option List
F.        
2-5 per 100,000 boys at birth
G.       
5-10 per 100,000 girls at birth
H.       
2-5 per 100,000 genetic males at birth
I.         
5-10 per 100,000 genetic females at birth
J.         
none of the above.
Question 2.
Lead-in
Which of the following sub-types of AIS do not exist?
Sub-types
1.        
complete AIS
2.        
incomplete AIS
3.        
mild AIS
4.        
partial AIS
5.        
total AIS
Option List
A.       
1
B.       
2
C.       
3
D.       
4
E.        
5
F.        
1 + 3
G.       
2 + 3
H.       
2 + 5
I.         
3 + 5
J.         
4 + 5
Question 3.
Lead-in
How common is partial AIS?
Option List
F.        
at least as common as complete AIS
G.       
at least as common as total AIS
H.       
less common than mild AIS
I.         
as common as incomplete AIS
J.         
none of the above.
Question 4.
Lead-in
How common is incomplete AIS?
Option List
A.       
at least as common as complete AIS
B.       
at least as common as total AIS
C.       
less common than mild AIS
D.       
as common as partial AIS
E.        
none of the above.
Question 5.
Lead-in
How common is mild AIS?
Option List
A.       
at least as common as complete AIS
B.       
at least as common as total AIS
C.       
less common than complete AIS
D.       
as common as partial AIS
E.        
none of the above.
Question 6.
Lead-in
No more prevalence!!
What is the mode of inheritance of AIS?
Option List
A.       
autosomal dominant
B.       
autosomal recessive
C.       
X-linked dominant
D.       
X-linked recessive
E.        
mitochondrial
Question 7.
Lead-in
What proportion of AIS is due to new mutations?
Option List
A.       
0%
B.       
1 – 20%
C.       
21 – 40%
D.       
41-60%
E.        
61-80%
Question 8.
Lead-in
Which gene is involved in AIS?
Option List
A.       
androgen receptor gene
B.       
aromatase receptor gene
C.       
androstenedione gene
D.       
oestrogen receptor gene
E.        
none of the above
Question 9.
Lead-in
How many mutations have been described of the gene which is involved in AIS?
Option List
A.       
0-10
B.       
11-100
C.       
101-200
D.       
201-300
E.        
>300
Question 10.
Lead-in
Which is the most common clinical presentation in AIS?
Option List
A.       
ambiguous genitalia
B.       
precocious puberty
C.       
premature menopause
D.       
primary amenorrhoea
E.        
secondary amenorrhoea
Question 11.
Lead-in
Which of the following are more common in AIS?
Option List
A.       
anlagen
B.       
coarctation of the aorta
C.       
“coast of Maine” pigmentation pattern
D.       
renal tract anomalies
E.        
none of the above.
Question 12.
Lead-in
A woman of 20 is found to have AIS. She has a pre-pubertal sister. What is the chance that the sister also has AIS, assuming that the condition is not due to a new mutation in the elder sister?
Option List
A.       
1 in 1
B.       
1 in 2
C.       
1 in 4
D.       
1 in 8
E.        
1 in 16
Question 13.
Lead-in
What is the risk of the gonads becoming malignant in AIS?
Option List
A.       
10%
B.       
20%
C.       
30%
D.       
> 30%
E.        
accurate risk not known

42.   EMQ. Classification of urgency of Caesarean section.
Topic. Classification of urgency of Caesarean section.
Abbreviations.
DDI:         decision-to-delivery interval
GP11.      RCOG’s Good Practice 11. 2010. Classification of urgency of Caesarean section – a continuum of risk.
Question 1.
Lead-in
How many categories are included in the classification of urgency in GP11?
Option List
K.        
3
L.        
4
M.     
5
N.       
6
O.      
7
Question 2.
Lead-in
What are the definitions used for the categories?
There is no option list! Just write your answers.
Question 3.
Lead-in
What additional aid is included in GP11 in relation to the classification of urgency?
Option List
K.        
a colour scale in the form of a spectrum
L.        
“red flag” numbering system
M.     
a table of the 10 most common reasons for high urgency classification
N.       
a table of the 10 most common reasons for low urgency classification
O.      
the web address of an app that automatically decides the urgency classification
Question 4.
Lead-in
What does GP11 say is the purpose of the additional aid?
Option List
F.        
it allows automatic, uniform classification
G.       
it highlights the degree of urgency to encourage efficient action by staff
H.       
it assists staff in learning the correct classifications
I.         
it encourages reflective learning
J.         
it reinforces the concept of ‘continuum  of urgency’
Question 5.
Lead-in
GP11 says: “Good communication is central to timely delivery of the fetus, while avoiding unnecessary risk to the mother”.
What does it say is a critical indicator of the DDI?
Option List
F.        
the grade of the senior anaesthetist
G.       
the grade of the senior obstetrician
H.       
the time from the delivery decision being taken until the theatre staff and anaesthetist have been fully informed
I.         
the time from the delivery decision being taken until the consent form is completed
J.         
the time for the woman to reach the operating theatre
Question 6.
Lead-in
GP11 devotes a section to communication. It makes 5 points. How many can you conjure up (useful for an OSCE station)?
Question 7.
Lead-in
GP11 gives a target DDI for C section for “fetal compromise” of 30 minutes. What it the rationale for this?
Option List
F.        
research shows that DDI ≤ 30 minutes is associated with best fetal outcomes
G.       
research shows that DDI ≤ 30 minutes is associated with best maternal outcomes
H.       
research shows that DDI ≤ 30 minutes is associated with best educational and neuro-developmental outcomes at age 7 years
I.         
it is an accepted audit tool that tests the efficiency of the delivery team
J.         
the NHSLA’s CNST requires that ≥ 90% of category 1 C sections have a DDI ≤ 30 minutes
Question 8.
Lead-in
GP11 had a concluding section entitled “Recommendations”, of which there were three. What were they?
Question 9.
Lead-in
Give two examples of clinical cases for each of the categories of risk.

43.   EMQ. APH.
Antepartum haemorrhage.
Lead-in.
The following scenarios relate to APH.
Pick one option from the option list.
Each option can be used once, more than once or not at all.
Option list.
A.        genital tract bleeding ≥ 500 ml. from 24 weeks until the delivery of the baby
B.         genital tract bleeding ≥ 500 ml. from 24 weeks until the delivery of the placenta.
C.         genital tract bleeding ≥ 500 ml. from 24 weeks, or earlier if the baby is live-born, until the delivery of the baby.
D.        1
E.         2
F.         3
G.        4
H.        5
I.           6
J.          7
K.         8
L.          9
M.      10
N.        15
O.        20
P.         30
Q.        50
R.         100
S.         500
T.         1,000
U.        true
V.        false
W.      none of the above
Scenario 1.
What is the definition of APH?
Scenario 2.
What is the upper limit in ml. for minor APH
Scenario 3.
What is the upper limit in ml. of major haemorrhage
Scenario 4.
What is the % risk of recurrence after 1 abruption?
Scenario 5.
What is the % risk of recurrence after 2 abruptions?
Scenario 6.
What is the major risk factor for placental abruption.
Scenario 7
List 10 risk factors for placental abruption.
Scenario 8
List 6 risk factors for placenta previa.
Scenario 9
In what % of pregnancies does APH occur?
Scenario 10
With regards to steps that can be taken to reduce the incidence of APH, what things would you include in a viva in the OSCE?