Monday, 21 May 2018

Tutorial 21st. May 2018



21 May  2018

1
How to prepare. What to read. Revision system. Study buddies. Statistics. Urogynae.
2
SBA. RCOG sample obstetric questions. Go through all of them as they feature in the exam and make for easy marks.
3
EMQ. Cystic fibrosis.
4
SBA.   Placenta accreta, increta & percreta.
5
SBA.  Cowden syndrome
6
EMQ. Clue cells, koilocytes etc.
7
Basic communication skills.

1.     How to prepare.
         I have written to Julie Morris and Kapil Kaur asking if they can give tutorials on statistics and uro-gynae respectively. Both are excellent teachers. The problem is the short time-scale until the exam.

2.     RCOG sample questions.

3.     Cystic fibrosis. There is no option list so you have to behave in a model fashion and decide the correct answer without assistance.
Question 1.
A woman is 8 weeks pregnant and known to be a carrier of cystic fibrosis.
Her husband is Caucasian.
What is the risk of the child having cystic fibrosis?
Question 2.
A healthy woman attends for pre-pregnancy counselling.
Her brother has cystic fibrosis. Her husband is Caucasian.
He has been screened for cystic fibrosis. The test was negative.
What is the approximate risk of them having a child with cystic fibrosis?
Question 3.
A healthy woman is a known carrier of cystic fibrosis.
She attends for pre-pregnancy counselling. Her husband has cystic fibrosis.
What is the risk of them having a child with CF?
Question 4.
A healthy woman attends for pre-pregnancy counselling. Her sister has had a child with cystic fibrosis.
What is her risk of being a carrier?
Question 5.
A woman attends for pre-pregnancy counselling. Her mother has cystic fibrosis.
What is the risk that she is a carrier?
Question 6.
A woman attends for pre-pregnancy counselling. Her mother has cystic fibrosis.
The partner’s risk of being a carrier is 1 in X.
What is the risk that she will have a child with CF?
Question 7.
A healthy Caucasian woman is 10 weeks pregnant.
Her husband is a known carrier of cystic fibrosis.
Which test would you arrange?
Question 8.
A woman attends for pre-pregnancy counselling. She has read about diagnosing CF using cffDNA from maternal blood. Is it possible to test for CF in this way?
Question 9.
A woman and her husband are known carriers of cystic fibrosis.
What is the risk of them having an affected child?
Question 10.
A woman and her husband are known carriers of cystic fibrosis.
What can they do to reduce the risk of having an affected child?
Question 11.
A woman and her husband are known carriers of cystic fibrosis.
Can CVS exclude an affected pregnancy?
Question 12.
A woman with cystic fibrosis is planning pregnancy. Her husband is a carrier of cystic fibrosis. What is the risk of having an affected child?
Question 13.
A woman with cystic fibrosis has a normal delivery of a healthy, 3.2 kg. baby at term. She has been advised not to breastfeed because her breast milk will be protein-deficient due to malabsorption.
Is this advice correct?
Question 14.
A woman with cystic fibrosis has a normal delivery of a healthy, 3.2 kg. baby at term. She has been advised not to breastfeed because her breast milk will contain abnormally low levels of sodium.
Is this advice correct?

4. Placenta accreta increta & percreta
This topic has been chosen to remind you of the existence of UKOSS and the various Reports it has produced as they would make perfect EMQs or SBAs.
Abbreviations.
Creta:      term to describe accreta, increta or percreta.
PET:         pre-eclampsia
PIH:          pregnancy-induced hypertension
Question 1.
Lead-in
Choose the best option from the option list for the definition of placenta accreta.
Option List
A.       
Placenta which is difficult to remove, but can be separated digitally
B.       
Placental villi  invade the decidua, but not the myometrium
C.       
Placental villi  invade the decidua and myometrium but not the serosa
D.       
Placental villi  invade the decidua, myometrium and serosa
E.        
Placental villi  invade adjacent organs, e.g. the bladder
Question 2.
Lead-in
Choose the best option from the option list for the definition of placenta increta.
Option List
A.       
Placenta is difficult to remove, but can be separated digitally
B.       
Placental villi  invade the decidua, but not the myometrium
C.       
Placental villi  invade the decidua and myometrium but not the serosa
D.       
Placental villi  invade the decidua, myometrium and serosa
E.        
Placental villi  invade adjacent organs, e.g. the bladder
Question 3.
Lead-in
Choose the best option from the option list for the definition of placenta percreta.
Option List
A.       
Placenta is difficult to remove, but can be separated digitally
B.       
Placental villi  invade the decidua, but not the myometrium
C.       
Placental villi  invade the decidua and myometrium but not the serosa
D.       
Placental villi  invade the decidua, myometrium and serosa
E.        
Placental villi  invade adjacent organs, e.g. the bladder
Question 4.
Lead-in
What is the approximate incidence of placenta creta in the UK?
Option List
A.       
1-2 per   1,000 deliveries
B.       
1-2 per   1,000 maternities
C.       
1-2 per   5,000 deliveries
D.       
1-2 per   5,000 maternities
E.        
1-2 per 10,000 deliveries
F.        
1-2 per 10,000 maternities
Question 5.
You need to be able to define “maternity” and know why it is important.
Lead-in
What is a “maternity”?
Option List
A.       
Any pregnancy, including ectopic pregnancy
B.       
Any pregnancy, excluding ectopic pregnancy
C.       
Any pregnancy resulting in a live birth
D.       
Any pregnancy resulting in live birth or stillbirth
E.        
Any pregnancy ending from 24 completed weeks plus any pregnancy resulting in a live birth.
Question 6.
Lead-in
Why is the term “maternity” important.
Option List
A.       
We should take best possible care of our pregnant patients
B.       
It is used as the denominator in calculations of the maternal mortality rate
C.       
It is used as the numerator in calculations of the maternal mortality rate
D.       
It is used as the denominator in calculations of the maternal mortality ratio
E.        
It is used as the numerator in calculations of the maternal mortality ratio
Question 7.
This question relates to risk factors for placenta accreta
Lead-in
Match each of the risk factors  listed below with an adjusted odds ratio from the Option List. Each option can be used once, more than once or not at all.
Note that some of the adjusted odds ratios show a reduced risk.
Risk factors and adjusted odds ratio.
Risk factor
Adjusted odds ratio
BMI > 30

Cigarette smoking in pregnancy

Ethnic group non-white

IVF pregnancy

Maternal age > 35

Parity ≥ 2

PIH or PET

Placenta previa diagnosed pre-delivery

Previous Caesarean section > 1

Previous Caesarean section x 1

Previous uterine surgery – not C. section







Option List
Adjusted odds ratio
0.53
0.57
0.66
0.9
1.0
2.0
3.06
3.4
3.48
10
14
16.31
32.13
65.02
102
Question 8.
Lead-in
This question relates to estimated incidence of placenta creta for various risk factors.
Match the risk factors with the estimated incidence in the option list. Each option can be used once, more than once or not at all.
Risk factors and estimated incidence per 10,000 maternities.
Risk factor
Estimated incidence
No previous C section

≥ 1 C section

Placenta previa not diagnosed pre-delivery

Placenta previa diagnosed pre-delivery

Previous C section but placenta previa not diagnosed pre-delivery

Previous C section + placenta previa diagnosed pre-delivery











Option List
0.3
0.6
1
3
5
9
108
577
1,000

5.     Cowden syndrome.
Scenario 1.
Lead in.
Which feature is associated with Cowden syndrome?
Option list.
A.     albinism
B.     hamartoma
C.     hammer-toe
D.     hypertrichosis
E.     stammer
Scenario 2.
Lead in. Which condition has the highest risk of occurrence in women with Cs?
Option list.
A.     breast cancer
B.     bowel cancer
C.     congenital absence of Müllerian tract derivatives
D.     hypertension
E.     hypothyroidism
Scenario 3.
Lead in. Which gynaecological cancer is a particular risk for women with Cs?
Option list.
A.     Bartholin’s gland cancer
B.     cervical cancer
C.     choriocarcinoma
D.     endometrial cancer
E.     vulval cancer
Scenario 4.
Lead in. Which cancer is more common in men with Cs?
Option list.
A.     breast cancer
B.     colon cancer
C.     melanoma
D.     renal cancer
E.     thyroid cancer
F.      all of the above

6.           Clue cells
Lead-in.
The following scenarios relate to genital infection.
Pick one option from the option list.
Each option can be used once, more than once or not at all.
Abbreviations.
Ct:                     Chlamydia trachomatis
FPA:                  Family Planning Association
HSV:                 Herpes simplex virus
LGV:                 lymphogranuloma venereum
Ng:                    Neisseria gonorrhoeae
Tv:                    Trichomonas vaginalis
Option list.
A
Actinomyces
B
Bacterial vaginosis
C
Bacteroides
D
Chlamydia trachomatis
E
Chlamydial infection of the genital tract
F
Herpes Simplex
G
Human Papilloma Virus
H
Lymphogranuloma venereum
I
Monilia
J
Neisseria gonorrhoeae
K
Trichomonas vaginalis

Scenario 1.                
Which option or options from the option list best fit with “clue cells”
Scenario 2.                
Which option or options from the option list best fit with “fishy odour”?
Scenario 3.                
Which option or options from the option list best fit with “flagellate organisms”?
Scenario 4.                
Which option or options from the option list best fit with “inflammatory smear”?
Scenario 5.                
Which option or options from the option list best fit with “koilocytes”?
Scenario 6.                
Which option or options from the option list best fit with “non-specific urethritis in the male”?
Scenario 7.                
Which option or options from the option list best fit with “strawberry cervix”?
Scenario 8.                
Which option or options from the option list best fit with “thin grey/ white discharge”?
Scenario 9.                
Which option or options from the option list best fit with “white, curdy discharge”?
Scenario 10.            
Which option or options from the option list best fit with “frothy yellow discharge”?
Scenario 11.            
Which option or options from the option list best fit with “protozoan”?
Scenario 12.            
Which option or options from the option list best fit with “obligate intracellular organism”?
Scenario 13.            
Which option or options from the option list best fit with “blindness”?
Scenario 14.            
Which option or options from the option list best fit with “LGV”?
Scenario 15.            
Which option or options from the option list best fit with “multinucleated cells”?
Scenario 16.            
Which option or options from the option list best fit with “serotypes D–K”?
Scenario 17.            
Which option or options from the option list best fit with “serovars L1-L3”?
Scenario 18.            
Which of the following are true in relation to Amsel’s criteria?
A
used for the diagnosis of bacterial vaginosis
B
used for the diagnosis of trichomonal infection
C
clue cells present on microscopy of wet preparation of vaginal fluid
D
flagellate organism present on microscopic examination of vaginal fluid
E
pH ≤ 4.5
F
pH > 4.5
G
thin, grey-white, homogeneous discharge present
H
frothy, yellow-green discharge present
I
fishy smell on adding alkali (10%KOH)
J
fishy smell on adding acid (10%HCl)
K
koilocytes present
L
absence of vulvo-vaginal irritation
Scenario 19.            
Which of the following are true in relation to Nugent’s Amsel’s criteria?
A
used for the diagnosis of bacterial vaginosis
B
used for the diagnosis of trichomonal infection
C
clue cells present on microscopy of wet preparation of vaginal fluid
D
pH ≤ 4.5
E
pH > 4.5
F
count of lactobacilli
G
count of Gardnerella and Bacteroides
H
count of white cells
Scenario 20.            
Garnerella vaginallis can be cultured from the vagina of what proportion of normal women?
A
< 10%
B
11 - 20%
C
21 - 30%
D
31 - 40%
E
41 - 50%
F
> 50%

7.     Basic communication skills.
         Now is the time to start practising communication skills, which are so important in the Part 3 exam. There is advice on my website: http://www.drcog-mrcog.info/MRCOG.htm. Click on the header ‘Topics like CNST and communication”. You have a lot of things to get polished before the exam – you don’t want to be trying to explain recessive inheritance for the 1st. time in front of an examiner!