Monday 30 January 2012

Tutorial 30 January 2012

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Tutorial

Tonight's topics were:

Maternal Mortality.
Lead-in.
The following scenarios relate to maternal mortality.
Pick the option that best answers the task in each scenario from the option list.
Each option can be used once, more than once or not at all.
Option List.
A.   Death of a woman during pregnancy and up to 6 weeks later, including accidental and incidental causes.
B.    Death of a woman during pregnancy and up to 6 weeks later, excluding accidental and incidental caused.
C.    Death of a woman during pregnancy and up to 52 weeks later, including accidental and incidental causes.
D.   Death of a woman during pregnancy and up to 52 weeks later, excluding accidental and incidental causes.
E.    A pregnancy going to 24 weeks or beyond.
F.    A pregnancy going to 24 weeks or beyond + any pregnancy resulting in a live-birth.
G.   Maternal deaths per 100,000 maternities.
H.   Maternal deaths per 100,000 live births.
I.      Direct + indirect deaths per 100,000 maternities.
J.     Direct + indirect deaths per 100,000 live births.
K.    Direct death.
L.     Indirect death.
M. Early death.
N.   Late death.
O.   Extra-late death.
P.    Fortuitous death.
Q.   Coincidental death.
R.    Accidental death.
S.    Maternal murder.
T.    Not a maternal death.
U.   Yes
V.   No.
W. I have no idea.
X.    None of the above.
Abbreviations.
MMR:      Maternal Mortality Rate.
MMRat:  Maternat Mortality Ratio.
SUDEP:    Sudden Unexplained Death in Epilepsy.            

Option list.

Scenario 1.
What is a Maternal Death?
Scenario 2.
A woman dies from a ruptured ectopic pregnancy at 10 weeks’ gestation. What kind of death is it?
Scenario 3.
A woman dies from a ruptured appendix at 10 weeks’ gestation. What kind of death is it?
Scenario 4.
A woman dies from suicide at 10 weeks’ gestation. What kind of death is it?

Scenario 5.
A woman with a 10-year-history of coronary artery disease dies of a coronary thrombosis at 36 weeks’ gestation. What kind of death is it?
Scenario 6.
A woman has gestational trophoblastic disease, develops choriocarcinomas and dies from it 24 months after the GTD was diagnosed and the uterus evacuated. What kind of death is it?
Scenario 7
A woman develops puerperal psychosis from which she makes a poor recovery. She kills herself when the baby is 18 months old. What kind of death is it?
Scenario 8
A woman develops puerperal psychosis from which she makes a poor recovery. She kills herself when the baby is 6 months old. What kind of death is it?
Scenario 9
What is a “maternity”.
Scenario 10
What is the definition of the Maternal Mortality Rate?
Scenario 11
What is the Maternal Mortality Ratio?
Scenario 12
A woman is diagnosed with breast cancer. She has missed a period and a pregnancy test is +ve. She decides to continue with the pregnancy. The breast cancer does not respond to treatment and she dies from secondary disease at 38 weeks. What kind of death is it?
Scenario 13
A woman who has been the subject of domestic violence is killed at 12 weeks’ gestation by her partner. What kind of death is it?
Scenario 14
A woman is struck by lightning as she runs across a road. As a result she falls under the wheels of a large lorry which runs over abdomen, rupturing her spleen and provoking placental abruption. She dies of haemorrhage, mostly from the abruption. What kind of death is it?
Scenario 15
A woman is abducted by Martians who are keen to study human pregnancy. She dies as a result of the treatment she receives. As this death could only have occurred because she was pegnant, is it a direct death?
Scenario 16
Could a maternal death from malignancy be classified as “Direct”.
Scenario 17
Could a maternal death from malignancy be classified as “Indirect”.
Scenario 18
Could a maternal death from malignancy be classified as “Coincidental”?
 
30th. January 2012

Essays.

With regard to smoking in pregnancy, critically evaluate:
1. risks to the mother,     4 marks
2. risks to the fetus,        4 marks
3. risks to the neonate,   4 marks
4. steps to reduce risks.  8 marks

A woman attends the antenatal clinic at 36 weeks. She had read an article in a woman’s magazine about the merits of umbilical cord blood banking and would like to have this done.
1. Justify the history you will take.                     4 marks
2. Justify the investigations you will arrange.    2 marks
3. Justify your management.                           14 marks      

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 

You are the sPR in the fertility clinic. A couple have been referred by their General Practitioner after basic investigation of their three years of infertility. She has never been pregnant, he has never made a partner pregnant.
1. Justify the history you will take.                              4 marks
2. Justify the investigations you will arrange.             6 marks
3. Outline the management and available options.  10 marks          

Friday 27 January 2012

Tutorial 26th. January 2012

Website:


Last night the programme I use to record the tutorial crashed and wiped the tutorial. Unfortunately, I did not notice or I might have been able to salvage some of it. You can still answer the questions and send them to me.
One thing I mentioned was a recent paper which raises questions about the use of the discriminatory zone:
http://www.jultrasoundmed.org/content/30/12/1637.abstract.


Missed pills. Starting the Pill. COC.
Lead-in.
The following scenarios relate to the combined oral contraceptive (COC) and missed pills.
For each, select the option that best fits the scenario.
Each option can be used once, more than once or not at all.
Abbreviations.
UPSI:     unprotected sexual intercourse.

Option list.
A.        pill that is ≥ 12 hours late.
B.        pill that is > 12 hours late.
C.        pill that is ≥ 24 hours late.
D.        pill that is > 24 hours late.
E.         two missed pills at any time in a single cycle.
F.         the first pill taken in one’s first love affair, now recalled with fond nostalgia for its effectiveness in preventing pregnancy, the Prince having been truly a loathsome toad.
G.       no additional contraception required.
H.        additional contraception required for 7 days.
I.          emergency contraception should be considered.
J.          emergency contraception should be recommended.
K.        take the missed pill immediately, but not if it means 2 pills in one day; no additional contraception needed; pill-free interval as normal.
L.         take the missed pill immediately, even if it means 2 pills in one day; no additional contraception needed; pill-free interval as normal.
M.      take the missed pill immediately, even if it means 2 pills in one day; additional contraception for 7 days; pill-free interval as usual.
N.       take one of the missed pills immediately, discard the other missed pills, use extra contraception for 7 days and discuss emergency contraception with your doctor.
O.       take the missed pills immediately, use extra contraception for 7 days and discuss emergency contraception with your doctor.
P.        continuous combined preparation.
Q.       bi-phasic preparation.
R.        quadriphasic preparation.
S.         cannot be answered from the data given.
T.         none of the above.


Scenario 1.
What is the definition of a missed pill?
Scenario 2.
What is the definition of two missed pills?
Scenario 3.
A COC is begun on day 1 of menstruation. What advice should be given about temporary additional contraception?
Scenario 4.
A COC is begun 5 days after day 1 of menstruation. What advice should be given about temporary additional contraception?
Scenario 5.
A COC is begun for the first time on day 1 of menstruation. The fifth pill is missed. What advice should be given?
Scenario 6.
A pill is missed on day 14 of a 21-day pack. What advice should be given?
Scenario 7
A pill is missed on day 21 of a 21-day pack. What advice should be given?
Scenario 8
Two pills are missed in the first week of a 21-day pack. What advice should be given?
Answer:
Scenario 9
Two pills are missed in the second week of a 21-day pack. What advice should be given?
Scenario 10
Two pills are missed in the third week of a 21-day pack. What advice should be given?
Scenario 11
What kind of preparation is Qlaira?

 
A nulliparous woman is admitted to the Early Pregnancy Unit with abdominal pain and bleeding. Her hCG is 2,000 i.u. per litre. An ultrasound scan shows an empty uterus and a left adnexal mass.
1.  Discuss the differential diagnosis.                                                           4 marks.
2.  Discuss the treatment options.                                                              10 marks.
3.  Discuss the advice you will give for when she has recovered.           6 marks.    

A nulliparous woman presents at 37 weeks’ gestation with reduced fetal movements. No fetal heart activity can be detected on auscultation.
1. Outline the steps necessary for diagnosis of fetal death in utero.  2 marks.
2. Outline the investigation.                                                                        4 marks.
3. Outline the management.                                                                      10 marks.
4. Outline the advice she should be given.                                                4 marks.

An immigrant woman is seen in the gynaecology clinic six months after the delivery of a stillborn baby. She complains of continuous urinary incontinence.
Outline the main themes for a comprehensive assessment and the main issues related to them.

A woman is referred to the gynaecology clinic with premenstrual syndrome.
Critically evaluate the investigation and management.


Monday 23 January 2012

Tutorial 23 January 2012


Tonight's topics are below.


Hepatitis B and pregnancy.
Lead-in.
Each of the following scenarios relates to hepatitis B and pregnancy.
Instructions.
For each scenario, select the most appropriate option from the option list.
Each option can be used once, more than once or not at all.
Abbreviations.
HBcAg:     hepatitis B core antigen
HBeAg:     hepatitis B e antigen         
HBsAg:     hepatitis B surface antigen
HBcAb:     antibody to hepatitis B core antigen
HBeAb:     antibody to hepatitis B e antigen
HBsAb:     antibody to hepatitis B surface antigen
HBIG:       hepatitis B immunoglobulin
HBV:         hepatitis B virus
Scenario 1.
An asymptomatic primigravida books at 10 weeks. Her partner had an acute HBV infection 4 months ago. What results on routine blood testing would indicate that she has an acute infection?
Scenario 2.
An asymptomatic primigravida books at 10 weeks. Her partner had an acute HBV infection 4 months ago. What results on routine blood testing would indicate that she is immune to the HBV as a result of natural infection?
Scenario 3.
An asymptomatic primigravida books at 10 weeks. Her partner had an acute HBV infection 4 months ago. What results on routine blood testing would indicate that she is immune to the HBV as a result of HBV vaccine?
Scenario 4.
An asymptomatic primigravida books at 10 weeks. Her partner had an acute HBV infection 6 months ago. What results on routine blood testing would indicate that she is a chronic carrier of HBV infection?
Scenario 5.
Testing shows that he is positive for HBsAg, positive for HBcAb but negative for IgM HBcAb. What does this mean in relation to his HBV status?
Scenario 6.
Testing shows that he is negative for HBsAg, positive for HBcAb and positive for HBsAb.
What does this mean in relation to his HBV status?
Scenario 7
A primigravid woman at 8 weeks gestation is found to be non-immune to the HBV. She has recently married and her husband is a chronic carrier. What should be done to protect her from infection?
Scenario 8
A woman is a known carrier of Hepatitis B. What is the risk of vertical transmission in the first trimester?
 Scenario 9
A woman is a known carrier of Hepatitis B. What is the risk of the neonate who has been infected by vertical transmission in the third trimester becoming a carrier without treatment?
Scenario 10
How effective is hepatitis B prophylaxis in preventing chronic carrier status developing in a neonate infected as a result of vertical transmission?
Scenario 11
Can a woman who is a chronic HBV carrier breastfeed safely?
Scenario 12.
Hepatitis B infection is the most dangerous of the viral hepatitis infections in pregnancy.
Scenario 13.
A pregnant woman who is not immune to HBV has a partner who is a chronic carrier. Can HBV vaccine be administered safely in pregnancy?
Scenario 14.
A pregnant woman who is not immune has a partner with acute hepatitis due to HBV. He cuts his hand and bleeds onto the kitchen table. How should she clean the surface to ensure that she gets rid of the virus?
Scenario 15.
Is it true that the presence of HBeAg in maternal blood is a particular risk factor for vertical transmission? Not really a scenario, but never mind!

Option list.
A.        acyclovir
B.        divorce
C.        HBcAg +ve
D.       HBeAg +ve
E.        HbsAg +ve
F.         HBsAg +ve; HBsAb –ve; HBcAb -ve
G.       HBsAg +ve; HBsAb –ve on two tests six months apart
H.       HBsAG –ve; HBsAb -ve on two tests six months apart
I.          HBsAg –ve; HBsAb +ve; HBcAb –ve
J.          HBsAg –ve; HBsAb +ve; HBcAb +ve
K.        HBsAg –ve; HBsAb +ve
L.         HBsAg +ve; HBcAg +ve
M.     HBV vaccine.
N.       HBIG
O.       HBV vaccine + HBIG
P.        immune as a result of infection
Q.       immune as a result of vaccination
R.        not immune
S.         chronic carrier of HBV infection
T.        10%
U.       30%
V.        50%
W.     60%
X.        70 - 90%
Y.        soap and boiling water
Z.        10% dilution of bleach in water
AA.   10% dilution of formaldehyde in alcohol
BB.   ultraviolet irradiation
CC.   yes
DD.  no
EE.    none of the above

Essays.
A woman is referred to the pre-pregnancy counselling clinic. She had Caesarean section with her previous pregnancy.
1.  Outline the history you will take.                    6 marks.
2.  Justify the investigations you will arrange.       4 marks.
3.  Justify the advice you will give.                      10 marks.

A woman is admitted for a gynaecological procedure.
1.   Outline why VTE is important and the strategies that hospital should employ to reduce their patients’ risks.                                                                                      4 marks.
2.   Discuss how risk assessment should be done for this woman.   8 marks.
3.   Outline the steps to be taken to reduce the risk of DVT.             8 marks.

A woman attends the pre-pregnancy counselling clinic. She plans her second pregnancy in the near future. Her sister recently had a baby with Down’s syndrome.
1.  Outline your agenda for the discussion.           4 marks
2.  Discuss the investigations you will arrange.     2 marks
3.  Justify the key information you will include. 14 marks

With regard to female genital mutilation (FGM).
1.   what are the key aspects of the law in the UK relating to FGM.                      2 marks.
2.   what are the responsibilities of the doctor who suspects that a child may be subjected to FGM?
                                                                                                                           2 marks.
3.   how is FGM graded?                                                                                    3 marks.
4.  outline the management of a woman                                                                                13 marks

Thursday 12 January 2012

Tutorial 12 January 2012


Tonight's topics are below.
The group had 25 minutes to answer the EMQ and write essay plans.
You should take 25 minutes to do the same and then listen to the tutorial.
If you are listening via a laptop, buy an external speaker to make a huge difference to the quality of the sound.
Even a cheap one makes a big difference.
Education.
I am not an expert in this topic and offer this as some help to working out answers if you get a question on teaching methods, which apparently has happened. If you are an expert and can help to improve what follows, that will be much appreciated.
If you get a question in the exam, please try to remember as much as possible, particularly the option list and send it to me.
There are often a variety of different techniques that could be used. I would guess that the exam committee will take care to restrict the option list so that it is clear which is the best option.
Lead-in.
The following scenarios relate to medical education
Pick one option from the option list.
Each option can be used once, more than once or not at all.
Abbreviations.
EMQ:    extended, matching question.
PBL:       problem-based learning.
Scenario 1.
A woman is admitted with an eclamptic seizure. The acute episode is dealt with and she is put on an appropriate protocol. You wish to use the case to outline key aspects of PET and eclampsia to the two medical students who are on the labour ward with you. Which would be the most appropriate approach?
Scenario 2.
You have been asked to provide a summary of the key aspects of the recent Maternal Mortality Meeting to the annual GP refresher course. There are likely to be 100 attendees. Which would be the most appropriate approach?
Scenario 3.
You have been asked to teach a new trainee the use of the ventouse. Which would be the most appropriate approach?
Scenario 4.
You have been asked to teach a group of medical students about PPH. To your surprise you find that they have good basic knowledge. Which technique will you apply to get the most from the teaching session?
Scenario 5.
Your consultant has asked you to get the unit’s medical students to prepare some questions about breech delivery which they can ask of their peers when they next meet. Which technique will you use?
Scenario 6.
You have been asked to discuss 2ry. amenorrhoea with your unit’s medical students. You are uncertain about the amount of basic physiology and endocrinology they remember from basic science teaching. Which technique will you use?
Scenario 7
The RCOG has asked you to chair a Green-top Guideline development committee. You find that there is very little by way of research evidence to help with the process. The College has assembled a team of consultants with expertise and interest in the subject. Which technique would be best to reach consensus on the various elements of the GTG?
Scenario 8
Which of the listed teaching techniques is least likely to lead to deep learning?
Scenario 9
An interactive lecture with EMQs is the best method of teaching. True or false.
Scenario 10
Only 20% of what is taught in a lecture is retained. True or false.
Scenario 11.
The main role of the teacher is information provision. True or false.
Scenario 12.
The main role of the teacher is to be a role model.  True or false.

Option list.
  1. brainstorming.
  2. brainwashing
  3. cream cake circle.
  4. Delphi technique.
  5. demonstration & practice using clinical model.
  6. doughnut round.
  7. interactive lecture with EMQs.
  8. lecture.
  9. 1 minute preceptor method.
  10. teaching peers / junior colleagues
  11. schema activation.
  12. schema refinement.
  13. small group discussion.
  14. snowballing.
  15. snowboarding.
  16. true
  17. false
 
Essays 12th. January 2012.

Question 1.

Discuss the contra-indications to the use of the COC.



Question 2.

Critically evaluate the uses of the levonorgestrel intra-uterine system, LNG-IUS.



Question 3.

A healthy, 25-year-old, nulliparous woman books at 8 weeks. She wishes to know what particular advice is relevant to her as she is married to a farmer.

1. outline the history you will take.                    6 marks

2. outline the investigations you will arrange.   4 marks

3. justify the advice you will give.                    10 marks.



Question 4.

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.