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Tonight we started with an EMQ and then went on to essays. I have been trying to work through the likely oncology topics. These are a problem unless you are a sub-specialty trainee. You don't have FIGO staging etc. at your fingertips. There is no easy answer. You just have to read it up and put it on your last-minute revision list.
The EMQ was as follows.
Read each of the following clinical scenarios and choose the best management from the list of options. Each option may be used once, more than once or not at all.
A. anticipate spontaneous vaginal delivery
B. perform biophysical profile.
C. perform fetal scalp pH sampling
D. perform fetal buttock skin pH sampling
E. arrange flow cytometry to assess for feto-maternal haemorrhage
F. correct maternal diabetic keto-acidosis and re-assess
G. exclude cephalo-pelvic disproportion
H. check for descent with contraction / maternal pushing
I. give steroids to promote fetal lung maturation.
J. deploy the APH protocol
K. start syntocinon
L. use the Kiwi
M. use the silastic ventouse
N. use Kiel land forceps
O. use Neville-Barnes forceps
P. use Spencer Wells forceps
Q. breech extraction
R. internal podalic version and breech extraction
S. elective Caesarean section
T. emergency Caesarean section
U. Caesarean hysterectomy
V. resign your post and become a Cistercian monk / nun
W. None of the above.
1. A primigravida with a 10 year history of IDDM is admitted at 30 weeks with diabetic ketoacidosis. The fetal heart rate is noted to 160 b.p.m. with loss of beat-to-beat variability and variable, late decelerations. What action will you take in relation to the fetal condition.
2. A primigravida with a 10 year history of IDDM with good glycaemic control has actively pushing in the second stage of labour for 2 hours. The first stage of labour lasted 8 hours. She has an effective epidural in place. The baby feels of average size and the scan estimate was of a birthweight of 7 – 8lbs. 1/5 of the fetal head is palpable abdominally. The position is OA with the head at the spines and a moderate degree of caput and moulding. What action, if any, will you take to expedite the delivery?
3. A 35-year-old woman has had two normal deliveries of babies weighing 7 and 8 lb. ten years before. Diabetes has been diagnosed in this pregnancy and has been well-controlled with diet. She is admitted at 39 weeks in spontaneous labour. The cervix is fully dilated and a flexed breech presentation is noted. The fetal heart rate is 100 beats per minute with poor variability and late decelerations. There is thick, fresh meconium. What action, if any, will you take to expedite the delivery?
4. A 35-year-old primigravida is admitted at 34 weeks with SROM and obvious liquor draining. Abdominal examination shown breech presentation. Her temperature is normal and her condition is good. A CTG shows a normal pattern. What will be your first action?
5. A 40-year-old woman has had two normal deliveries of babies weighing 7 and 8 lb. ten years before. After a first stage lasting 5 hours she has sudden pain and fresh bleeding. The fetal heart rate drops to 90 beats per minute with no recovery over a period of 5 minutes. The cervix is noted to be almost fully dilated with only a thin rim of cervix anteriorly. The position is OA with the head 2 cm. below the spines. There is minimal caput and moulding. What action will you take to expedite the delivery after sending a midwife to call for help?
6. A primigravida has spontaneous onset of labour at 40 weeks. The first stage last for 15 hours. After active pushing in the second stage for 2 hours, she is becoming tired. The CTG is normal and the liquor is clear. Abdominal examination shows 1/5 of the fetal head to be palpable. The presenting part is at the ischial spines. The position is occipito-transverse with moderate caput and moulding. There is no descent of the presenting part with contractions and pushing. What action, if any, will you take to expedite the delivery?
7. A primigravida has spontaneous onset of labour at 40 weeks. The first stage last for 15 hours. After active pushing in the second stage for 2 hours, she is becoming tired. The CTG is normal and the liquor is clear. Abdominal examination shows 0/5 of the fetal head to be palpable. The presenting part is at the ischial spines. The position is occipito-transverse with moderate caput and moulding. There is some descent of the presenting part with contractions and pushing. What action, if any, will you take to expedite the delivery?
8. A primigravida at 32 weeks has been pushing in the second stage for 90 minutes. The first stage lasted for 6 hours and was of spontaneous onset. Maternal condition is good. You have been summoned as the CTG shows bradycardia, loss of variability and late decelerations. The head is not palpable abdominally and the position is occipito-anterior and the station 1 cm. below the ischial spines. What action, if any, will you take to expedite the delivery?
9. A woman of 45 years from a traveller family has had 5 normal deliveries of babies weighing from 4 to 4.5kg. The youngest child is 10 years old. She is admitted in advanced labour having had no antenatal care. Examination shows the cervix to be fully dilated with the head presenting 1 cm above the spines in an occipito-anterior position. There is moderate caput and moulding. She is obese, but the fetal head is thought to be 1/5 palpable. There is evidence of fetal compromise with loss of variability and late decelerations. What action, if any, will you take to expedite the delivery?
10. A woman of 30 years with a history of elective Caesarean section for breech presentation in her only previous pregnancy is in labour after a consultant decision that her wish for VBAC is appropriate. After 6 hours in labour she complains of sudden lower abdominal pain. A small amount of fresh blood is noted. The CTG shows sudden onset of compromise with a rate of 80 beats per minute, loss of variability and variability. What action, if any, will you take to expedite the delivery?
The essays were as follows.
Question 1.
A 35 year-old woman books at 6 weeks. She has noted a left breast mass. Breast cancer is suspected.
1. What is the life-time risk of female breast cancer? 1 mark.
2. How does pregnancy affect the risk of breast cancer? 4 marks.
3. Outline the investigation. 5 marks.
4. Critically evaluate the management. 10 marks.
Question 2.
Critically evaluate HRT in relation to breast cancer.
Question 3.
Outline the FIGO classification system for ovarian cancer and how staging influences treatment.
Question 4.
A woman of 48 is referred with erratic vaginal bleeding for six months. She has had an intra-uterine contraceptive in place for five years. She has occasional hot flushes.
1. Justify the things you will focus on in taking her history. 6 marks
2. Justify the investigations you will perform. 6 marks
3. Justify the advice you will give. 8 marks
Question 1.
Breast cancer & pregnancy has not come but may do so as there is a TOG article from 2010: Volume 12, Issue 3, July 2010, Pages: 186–192.
Question 2.
Breast cancer and HRT came in 2000 and 2004, so could reappear any time, particularly as there was a TOG article in 2010. Volume 12, Issue 3, July 2010, Pages: 155–163.
Question 3.
Outline the FIGO classification system for ovarian cancer and how staging influences treatment.
Ovarian cancer has featured as follows:
Cancer: ovarian. Morbidity of chemotherapy. How to reduce | March | 1999 |
Cancer: ovarian. Objectives of surgery | Sept | 1998 |
Cancer: ovarian: +ve family history. Discuss screening | Sept | 2005 |
There was a TOG article in 2007 on management of early disease. Volume 9, Issue 4, October 2007, Pages: 243–247.
Question 4.
This essay came in 1998. It is one of those difficult “easy” essays in which you have to cover a lot of points.
As usual, send me your versions, written under exam conditions, and I'll send mine - if I have written them.
