Tutorial 24th. February 2011

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Tonight we started with an EMQ. I wrote it just before the tutorial and have not yet had time to write the answer. Send me your answer and I'll send mine as soon as it is done.

Early pregnancy complications.

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.

Abbreviations.

AFC.         antral follicle count.

AMH.        anti-Mullerian hormone.

CRL.         crown-rump length.

EPU.         early pregnancy unit.

FSH.         follicle stimulating hormone.

GTD.         gestational trophoblastic disease.

GTG 17.    RCOG Green-top Guideline 17. ”Recurrent Miscarriage.”  2003.

GTG 25.    RCOG Green-top Guideline 25. ”The Management of Early Pregnancy Loss.“ 2006.

hCG.        human chorionic gonadotrophin

MEUC.     medical evacuation of uterine contents.

PUL.         pregnancy of unknown location.

PUV.        pregnancy of uncertain viability.

RM.          recurrent miscarriage.

SEUC.     surgical evacuation of uterine contents.

TVS.         trans-vaginal scan

USS.        ultrasound scan

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 1^st. 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?

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.     Counsel re missed miscarriage and refer to the EPU.

K.    Explain diagnosis and refer to the EPU for PUL protocol.

L.    Explain diagnosis and refer to the EPU for PUV protocol.

M.   Manage as ectopic pregnancy until proven otherwise.

N.    Arrange progesterone assay.

O.   Arrange AFC.

P.    Arrange AMH assay.

Q.   Arrange serial hCG monitoring for 48 hours.

R.    Administer anti-D immunoglobulin.

S.    Administer ergometrine 0.5 mg i.m.

T.    Prescribe mifepristone.

U.    Prescribe misoprostol for vaginal use.

V.    Continue with routine booking.

Then we moved on to essay plans.

 

81. A woman attends for a routine fetal anomaly scan at 20 weeks. Hydrops fetalis is diagnosed.

1. List the main causes of hydrops fetalis at 20 weeks.    8 marks.

2. Justify the history you will take.                                  4 marks.

3. Justify the investigations you will arrange.                   4 marks.

4. Justify your management.                                          4 marks.              

82. A woman attends for a routine fetal anomaly scan at 20 weeks. Echogenic bowel is seen.

1. List the main causes of echogenic bowel at 20 weeks.         6 marks.

2. Justify the history you will take.                                           4 marks.

3. Justify the investigations you will arrange.                            4 marks.

4. Justify your management.                                                    6 marks.              

83. A woman attends for a routine fetal anomaly scan at 20 weeks. Bilateral choroid plexus cysts are noted.

1. List the main associations of choroid plexus cysts at 20 weeks.  6 marks.

2. Justify the history you will take.                                                 4 marks.

3. Justify the investigations you will arrange.                                  4 marks.

4. Justify your management.                                                          6 marks.            

84. A 32 year-old woman with learning difficulty attends the gynaecology clinic with her mother. The referral is because of severe dysmenorrhoea and menorrhagia. The mother is keen for her to have hysterectomy and is prepared to give her consent.

1.  What factors will you take into consideration before offering treatment?            8 marks.

2.  Outline the treatment options, not including hysterectomy, that you will discuss. 6 marks.

3.  If it is concluded that hysterectomy is the best option, justify the steps you will take to arrange this.                                                                                                                 6 marks.     

Next week we will not meet to allow last-minute revision. The next week is the week of the exam and we won't meet. The next tutorial will be on Monday 14th. March.         

Tutorial 21 February 2011

Podcast.

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Tonight we discussed the following essay plans:

76.  There has been a recent spate of requests for Caesarean section with no medical grounds. The Clinical Director has asked you to produce a provisional policy document on the subject for discussion at a Unit meeting with a view to formulating Unit policy.

Justify the issues and facts you will include in the paper.

 77.  A healthy, 27 year-old-couple are being investigated for infertility, neither having a child. Semen analysis has shown Azoospermia. You see them for review in the gynaecology clinic.

1. outline the information you will provide.    3 marks

2. justify the history you will take.                     3 marks

3. justify the investigations you will arrange.   8 marks

4. outline the treatment options.                       8 marks            

78.   A 32-year-old woman attends for pre-pregnancy counselling before embarking on her second pregnancy. She has a daughter of 5 years who was born with congenital adrenal hyperplasia.

1. Justify the history you will take.                                                                   4 marks.

2. Justify the investigations you will arrange.                                                 4 marks

3. What is the chance that the next pregnancy will be affected by CAH.  2 marks                                                 

4. Justify the advice you will give.                                                                    10 marks             

79.   Critically evaluate bariatric surgery in relation to obstetrics.            

80.   Discuss how the impact of sepsis in obstetric units might be reduced.  

As we have now reached topic 80 for this session, I hope that we have managed to spot at least two of the essays.   

Tutorial 17th. February 2011

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Tonight we discussed the following essay plans:

72     Describe the pre-conceptual counselling that you would offer a 25- year-old nulliparous woman whose natural father suffers from Haemophilia A (Factor VIII deficiency).

This essay, worded as above, came in 1997.        

73     A 30-year old woman presents with supra-pubic pain unless her bladder is empty and frequency of micturition. Several MSSUs have shown no evidence of infection.

1. Justify the history you will take.                    6 marks

2. Justify the investigations you will arrange.      6 marks

3. Justify your management.                             8 marks

This has not come in the essays, but there was a TOG article in 2007 and one in OGRM in 2009.  

74     A woman with a twin pregnancy reports reduced fetal movements at 30 weeks. An USSS shows the demise of one fetus.

1. Justify the history you will take.                    6 marks

2. Justify the investigations you will arrange.  6 marks

3. Justify your management.                               8 marks

This topic came in the essays in 1998, but not since. Twins + prem labour came in 06 and TTS in 08. TOG had a good article on controversies in the mgt of twins in 2010 and one on twins in the same year. It has to come soon and my guess is that demise of one twin is the likeliest. 

75     With regard to domestic violence:

1. Outline why it is important.                                                           6 mks.

2. Outline the key aspects of the mgt.of a case of DV.                     10 mks.

3. How may the detection of DV be improved?                                 8 mks.

This came in the essays in 2001 and 2007.

We finished these by 20.30, so went back to essay 63 that we had not had time to discuss last week.

63     You have been asked to prepare a lecture on risk management in obstetrics for the trainees in your department.

Critically evaluate the key messages you will include in the presentation.              

We have done well to get up to essay topic 75 in this session, particularly as we have 2 weeks to go to the exam.

Tutorial 14th. February 2011

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Tonight's topics were:

First an EMQ.

Lead-in.
The following scenarios relate to haemophilia A, factor VIII deficiency (HA).
For each, select the most appropriate answer from the option list.
Each option can be used once, more than once or not at all.

Scenario 1.
A woman attends for pre-pregnancy counselling. Her brother has haemophilia A. What is her risk of being a carrier?
Scenario 2 .
A woman attends for pre-pregnancy counselling. Her father has haemophilia A. What is her risk of being a carrier?
Scenario 3.
If she is tested and found to be a carrier, what tests will you arrange for her partner?
Scenario 4.
If she is a carrier, what is the risk to her male offspring?
Scenario 5.
If she is a carrier, what is the risk to her female offspring?
Scenario 6.
If she is a carrier and her partner tests has haemophilia A, what are the risks to their female offspring?
Scenario 7.
If she is a carrier and her partner has haemophilia A, what are the risks to their male offspring?
Send me your answers and I'll send my version with explanation. I wrote the EMQ just before the tutorial and haven't had time to do an option list, so just work out what the answer should be. Good EMQ technique, anyway, as this is what you are advised to do first, then to check the option list.

Then we did some essays:
68 An obese woman of 25 is referred to the gynaecology clinic with oligomenorrhoea and a scan showing polycystic ovaries.
1. What are the diagnostic criteria for PCOS? 2 marks
2. What investigations will you arrange to confirm that she has PCOS and to help you advise about management? 4 marks
3. Justify your management if PCOS is diagnosed. 14 marks

69 With regard to gestational diabetes:
1. what are the diagnostic criteria? 2 marks
2. justify your views on screening for gestational diabetes. 4 marks
3. outline the key aspects of management 14 marks

70 A woman of 75 is referred to the gynaecology clinic with prolapse of the vaginal vault. She had hysterectomy some years before.
1. Outline the key elements of the history. 4 marks
2. Justify the investigations you will arrange. 6 marks
3. Justify the discussion you will have with her about the treatment options. 10 marks
The RCOG likes this topic. It came in the essays in 2001, 2005 and 2008.
There is a Green-top from 2007.

71 You have been asked to write a protocol for the diagnosis and management of umbilical cord prolapse.
1. Justify the steps you will take. 6 marks
2. Justify the key advice you will include in the protocol. 14 marks
Cord prolapse has not come in the essays, but there is a Green-top guideline from 2008.

72 Describe the pre-conceptual counselling that you would offer a 25- year-old nulliparous woman whose natural father suffers from Haemophilia A (Factor VIII deficiency).
This essay, worded as above, came in 1997.

We didn't manage numbers 70 and 72, but will do so next time.

There is a Green-top guideline on vault prolapse.

Tutorial 10th. February 2011

Podcast.http://soundcloud.com/drtmcf/tutorial-10-february-2011.

Website.www.drcog-mrcog.info.

Tonight's topics were:

64 With regard to hyperemesis gravidarum.
1. Outline how the diagnosis is made. 2 marks
2. Outline the immediate consequences. 6 marks
3. Outline the consequences in later pregnancy. 6 marks
4. Justify your management of a woman seen with HG at 10 weeks. 6 marks
This came in the essays in 2004.

65 A woman is admitted at 8 weeks with an ectopic pregnancy.
1. Critically evaluate the medical treatment options. 8 marks.
2. Critically evaluate the surgical options. 12 marks.

66 You have been asked to give a lecture on the Mental Capacity Act 2005 using illustrative case examples.
Describe the types of cases you will use and the key points you will make.

67 A woman of 38 is referred to the gynaecology clinic as the tail of her IUCD could not be seen when she recently had a routine cervical smear.
1. Outline the history you will take. 6 marks.
2. Justify the investigations you will arrange. 4 marks.
3. Justify your management. 10 marks.

It is nice to see that we are now up to topic 67.
We did not manage the Mental Capacity Act question.
It is discussed in MCQ 12, question 4.

Tutorial 7th. February 2011

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Tonight's topics were:


First of all some MCQs from Asha.

Masculinization of cloaca is dependent on 5 alpha reductase activity

Wolffian structure development is independent of 5 alpha reductase activity.

Achondroplasia is associated with polyhydramnios

Achondrogenesis is associated with polyhydramnios

Talipes equinovarus is characteristically associated with oligohydramnios.

The risk of a 45 year old woman having a child with neural tube defect is much higher than that of a 18 year old woman.

Recognised association of oligomenorrhoea includes chronic renal failure

Cystic glandular hyperplasia of endometrium  is a recognised association of oligomenorrhoea .

Uncontrolled maternal pre-gestational diabetes and a HBa1c of 11 increases the risk of aneuploidy.

Women with a history of subfertility have an increased risk of preterm labour

Rubella infection in first trimester is associated with oligohydramnios

Severity of hyperemesis is directly related to serum levels of HCG

Hyperemesis gravidarum is associated with fetal growth restriction.

Ondansetron  is safe to use in the first trimester.

Neonatal Jaundice appearing on 3rd day and still present at 2 weeks of age may be due to HDN, Galactosaemia, phenylketonuria, neonatal hyperthyroidism. Pick out the ones that are true.

Use of muscle relaxants is a predisposing factor for maternal pulmonary aspiration of gastric contents.

Send my your answers and I'll send you what I think.

Then we managed some essays:

59           A 25-year-old-woman had her first child by normal delivery in the night. She plans to go home today. She intends to breast-feed for at least six months. You have been asked to see her to discuss contraception.

1.  Justify the history you will take.           6 marks.

2.  Justify the advice you will give.           14 marks.             

60           You are the SpR in the gynaecology clinic. A 30-year-old woman is referred for advice about heavy periods.

1.  Justify the history you will take.                      6 marks.

2.  Justify the examinations you will perform.   2 marks.

3.  Justify the investigations you will arrange.   2 marks.

4.  Justify the advice you will gi ve.                     10 marks.  

61           A nulliparous woman of 30 years attends for pre-pregnancy counselling. She has had epilepsy since the age of 10 years.

1.  Critically evaluate the history you will obtain.                 6 marks.

2.  Critically evaluate the investigations you will arrange.  2 marks.

3.  Critically evaluate the advice you will give.                    12 marks.

Essay in 1999 and 2004. 

62           You have been asked to prepare a lecture on risk management in gynaecology for the trainees in your department.

Critically evaluate the key messages you will include in the presentation.                             

63           You have been asked to prepare a lecture on risk management in obstetrics for the trainees in your department.

Critically evaluate the key messages you will include in the presentation.                           

 It is pleasing to note that we are now up to topic number 63 for this session. With luck we should get up to 80 by the time of the exam.

Tutorial 3rd. February

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Tonight we discussed an EMQ about cystic fibrosis. This is a favourite for the exam. There are some examples in MCQ Paper 2, question 1 or, more precisely, in the answer, but you are best to start with the question and work towards the EMQs.

 

The topics we discussed were as follows:

 

1.    How may the morbidity and mortality associated with vasa previa be reduced?

            TOG 2008.

2.    A 20 year-old woman with a known history of drug abuse attends the hospital antenatal booking clinic in her first pregnancy.

a.    outline the factors determining her level of risk       4 marks.

b.    outline the risks to the mother                                  6 marks.         

c.    outline the risks to the fetus                                      4 marks.

d.    outline the risks to the neonate & infant                   4 marks.

e.    outline the risk to others                                            2 marks.

TOG 2000, OGRM 2010.

3.    Critically evaluate the non-contraceptive benefits of combined oral contraception.

       Essays 1998

4.    A woman complains of breakthrough bleeding on oral contraception.

a.    justify the history you will take                                  6 marks.

b.    justify the examination you will perform.                  4 marks.

c.    justify the investigations you will arrange.                4 marks.

d.    justify the advice and treatments you will give.        6marks.

FSRH guideline.

5.    A woman is referred to the gynaecology clinic requesting sterilisation.

a.    Critically evaluate the history you will take.                     8 marks.

b..   Critically evaluate the advice you will give.                   12 marks.