30 December 2013

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Tonight we discussed one EMQ and five SAQ plans.
I hope you have a happy and healthy New Year.
And a successful one if you are sitting the part 2 exam.

4	EMQ. Antenatal steroids	30	Dec	2013
42	A 55-year-old woman is referred to the gynaecology clinic. A friend of the same age has recently been found to have osteopenia and has been started on a bisphosphonate drug. She wishes to discuss her risk of osteoporosis and what she can do to reduce it. 1. Discuss how her risk of osteoporosis can be assessed.                        6 marks 2. Critically evaluate the steps that can be taken to reduce her risk.  14 marks	30	Dec	2013
43	With regard to nuchal translucency. a. What is nuchal translucency, how is it measured and what are     the important values?  6 marks b. When is it measured and why are other times not used?     4 marks c. Critically evaluate the uses and implications of NT     measurement.      10 marks.	30	Dec	2013
44	With regard to pertussis and pregnancy. 1.            What is pertussis caused by, how is it spread, what kind of vaccine is available and can it be used in pregnancy?          4 marks. 2.            What are the important epidemiological facts in relation to pertussis in the UK in 2012 and 2                                         3 marks 3.            What is the current advice in the UK about pertussis in pregnancy and who creates the advice?                                        3 marks. 4.            Critically evaluate the justification for the advice.  10 marks.	30	Dec	2013
45	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.	30	Dec	2013
46	Your consultant is on leave. The Secretary gives you a histology report relating to a 24-year-old woman who had suction evacuation for incomplete miscarriage 10 days before. The histology report is diagnostic of complete hydatidiform mole. 1.  Justify your immediate management.     8 marks 2.  Detail the subsequent management.    12 marks.	30	Dec	2013

Antenatal steroids and the neonate.

Lead-in.

The following scenarios relate to antenatal steroid use and the neonate.

Pick one option from the option list.

Each option can be used once, more than once or not at all.

Abbreviations.

ANS:      antenatal steroids.

FGR:      fetal growth restriction.

GTG:     Green-Top Guideline No 7 from the RCOG. “Antenatal Corticosteroids to Reduce Neonatal Morbidity and Mortality.”

RDS:      respiratory distress syndrome. Now better known as “surfactant-deficient lung disease of the new-born”.

Option list.

There is no option list.

I want you to come up with your answers.

Scenario 1.

What are the benefits to the neonate of appropriate administration of antenatal steroids?

Scenario 2.

At what gestations should antenatal steroids be offered to women with singleton pregnancies who are at risk of premature labour?

Scenario 3.

At what gestations should antenatal steroids be offered to women with multiple pregnancies who are at risk of premature labour?

Scenario 4.

What advice is contained in the GTG in relation to very early gestations, threatened premature labour and the use of antenatal steroids.

Scenario 5.

What advice is contained in the GTG in relation to antenatal steroids and Caesarean section?

Scenario 6.

What advice is given in the GTG about ANS in relation to the fetus with FGR at risk of premature delivery?

Scenario 7

What advice is given in the GTG in relation to ANS for women with IDDM?

Scenario 8

What advice is in the GTG in relation to adverse effects of ANS on the fetus?

Scenario 9

What advice is in the GTG in relation to short-term maternal adverse effects?

Scenario 10

What contraindications to ANS are cited in the GTG?

Scenario 11

What is the recommended drug regime for ANS administration?

Scenario 12.

What is the time-scale for maximum effect of ANS in reducing RDS?

Scenario 13.

When should repeat courses of ANS be given?

Tutorial 23 December 2013

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https://soundcloud.com/drtmcf/23-december-2013

Tonight we were going to write write 4 essay plans do an EMQ and have a role-play.
As you will see, we did not quite manage.
The role-play was just to remind you that you need to be thinking about and practising your communication skills now and not leaving it until after March.

10	EMQ. Maternal Mortality definitions
38	A 25-year-old primigravida attends for a routine scan and echogenic bowel is noted. 1. What is the advice of the National Screening Committee in relation to “soft markers”?                                                6 marks. 2. What conditions are linked to echogenic bowel?     6 marks. 3. Justify your management.                                           12 marks.
39	With regard to breastfeeding. a. what are the benefits of breastfeeding?                          8 marks b. what are the contraindications to breastfeeding?         4 marks c. what are the WHO recommendations about duration of breastfeeding?    2 marks d. What can be done to promote breastfeeding?                6 marks
40	Critically evaluate Down’s syndrome screening.
41	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 and justify your agenda for the discussion.        4 marks 2.  Critically evaluate the investigations you will arrange.    4 marks 3.  Justify the key information you will include.                   12 marks
42	Roleplay . The woman in the above pre-pregnancy clinic now in OSCE scenario.

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 causes.

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:  Maternal 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 pregnant, 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”?

Tutorial 19th. December 2013

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https://soundcloud.com/drtmcf/19-december-2013

Tonight we wrote 5 essay plans and answered an EMQ.

For the next 2 weeks we will have tutorials on the Mondays, but not the Thursdays.

Topics 19 December 2013

9	EMQ. Mental Capacity.
33	You have been put in charge of introducing a policy in the antenatal clinic for the management of domestic violence. Your recommendations have been accepted by the senior staff in the department and the launch date for the new policy in is 3 months. You have been asked to give a lecture to the midwives detailing the important issues relating to the introduction of the policy. Critically evaluate the topics you will include in the lecture.
34	A 20-year-old woman is referred to the gynaecology clinic with a complaint of hirsutism. Critically evaluate the management. 1.  Outline the necessary facts to obtain from the history.  6 marks. 2.  Justify the investigations you would arrange.                    8 marks. 3.  Outline the key aspects of the management.                                  6 marks.
35	A 41-year-old woman attends for review after a normal hysteroscopy. She now wishes treatment for her incapacitating heavy periods which have not responded to medical management. 1. Outline the history you will take.                        4 marks.    2. Outline the investigations you will consider.        4 marks. 3. Critically evaluate your management.               12 marks
36	Critically evaluate neonatal screening.
37	Discuss the key aspects of neonatal jaundice. a. why it is important.                        4 marks. b. the causes of neonatal jaundice. 8 marks. c. the management.                            8 marks.

Mental Capacity Act 2005.

Lead-in.

The following scenarios relate to the Mental Capacity Act 2005.

Pick one option from the option list.

Each option can be used once, more than once or not at all.

Abbreviations.

CAD:      Court-appointed Deputy.

COP:      Court of Protection.

FGR:      fetal growth restriction.

LPA:       Lasting Power of Attorney.

MCA:    Mental Capacity Act 2005.

PoA:      Power of Attorney.

Option list.

A.        Yes

B.        No

C.        True

D.        False

E.         Does not exist

F.         The husband

G.       A parent

H.        The child

I.          the General Practitioner

J.          the Consultant

K.        the Registrar

L.         The Consultant treating the patient

M.      A Consultant not involved in treating the patient

N.       The Medical Director

O.       A person with Powers of Attorney

P.        The sheriff or sheriff’s deputy

Q.       Balance of probabilities

R.        Beyond reasonable doubt

S.         None of the above.

Scenario 1.

A person with LPA is normally not a family member.

Scenario 2.

A Sheriff’s Deputy is normally not a family member.

Scenario 3.

A person with PoA can consent to treatment for the patient who lacks capacity.

Scenario 4.

A Court-appointed Deputy can consent to treatment for the patient who lacks capacity, but must go back to the Court of Protection if further consent is required for additional treatment.

Scenario 5.

A person with PoA can authorise withdrawal of all care except basic care in cases of individuals with persistent vegetative states.

Scenario 6.

An advance decision can authorise withdrawal of all but basic care in cases of persistent vegetative states.

Scenario 7

A person with PoA cannot overrule an advance direction about withdrawal or withholding of life-sustaining care.

Scenario 8

A woman is seen in the antenatal clinic at 39 weeks’ gestation. Her blood pressure is 180/110 and she has +++ of proteinuria on dipstick testing. She has mild epigastric pain. A scan shows evidence of FGR with the baby on the 2^nd. centile. Doppler studies of the umbilical artery are abnormal and a non-stress CTG shows loss of variability and variable decelerations. She is advised that she appears to have severe pre-eclampsia and is at risk of eclampsia and of intracranial haemorrhage. She is told of the associated risk of mortality and morbidity. She is also advised that the baby is showing evidence of severe FGR and has abnormal Doppler studies and CTG which could lead to death or hypoxic damage. She declines admission or treatment. She says she trusts in God and wishes to leave her fate and that of her baby in His hands. She is seen by a psychiatrist who assesses her as competent under the MCA and with no evidence of mental disorder. The obstetrician wants to apply to the COP for an order for compulsory treatment. Can he do this?

Scenario 9

A woman is admitted at 36 weeks’ gestation with evidence of placental abruption. She is semi-comatose and shocked. There is active bleeding and the cervical os is closed. Fetal heart activity is present but with bradycardia and decelerations. The consultant decides that Caesarean section is the best option to save her live and that of the baby. When reading the notes, the registrar comes across an advance notice drawn up by the woman and her solicitor. It states that she does not wish Caesarean section, regardless of the risk to her and the baby. The consultant tells the registrar that they can ignore it now that she is no longer competent and get on with the Caesarean section for which she will be thankful afterwards. The registrar says that the advance notice is binding. Who is correct?