Tutorial 31 January 2013

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Julie Morris will be giving a tutorial on medical statistics on Thursday 7th. February.
To get the most out of it you should revise your basic statistics and read the two tutorials on basic statistics on her website: http://www.south.manchester.ac.uk/medicalstatistics/information.asp

EMQ. Turner’s syndrome.           

With regard to prolactin.

1. What is it and what are its control mechanisms?                4 marks

2. Define and outline the main causes of hyperprolactinaemia.4 marks

3.  Critically evaluate prolactin in relation to fertility.             14 marks

A woman is to be 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 you will take to reduce her risk of VTE.       8 marks.              

A woman with BMI of 35 attends for pre-pregnancy counselling.

1. Outline the reasons that obesity is causing concern in relation to pregnancy. 6 marks

2. Justify the investigations you will arrange.                                                    2 marks

3.  Justify your management.                                                                          6 marks

4. Outline the key aspects of antenatal care.                                                6 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 woman found at booking to have had FGM.     13 marks.

Turner’s  syndrome.

This is supposed to be an EMQ, but some of the questions are MCQ with “True” and “False” answers, so I have put these in the answer list. But it includes everything I think you might be asked about Turner’s.

Option list

1 in   500

1 in 1,000

1 in 1,500

1 in 2,000

1 in 2,500

1 in 3,000

1 in 10,000

1 in 50,000

0%

0.1%

1 %

2%

5%

10%

15%

20%

25%

30%

40%

50%

60%

70%

80%

90%

> 90%

Most common

2^nd. most common

True

False

Answer not on this option list.

Questions.

1.      TS is due to 45XO.                                                

2.      What is the incidence of TS?                                  

3.      The incidence of TS rises with maternal age?           .

4.      Most cases of TS are due to loss of a paternal chromosome. 

5.      How common in monosomy X in TS?                     

6.      How common is monosomy Y in TS?                     

7.      What % of miscarriages are due to TS?                  

8.      What % of TS pregnancies miscarry?                     

9.      ↑ NT is a feature of TS                                           

10.    ↑ NT is a feature of congenital heart disease           

11.    Low birth weight is a feature of TS.                         .

12.    If TS is suspected, but the neonate’s karyotype from blood testing is normal, the diagnosis is Noonan’s syndrome.                               .

13.    Neonates are at normal risk of developmental dysplasia of the hip. 

14.    Immune hydrops is more common in TS.                

15.    Cystic hygroma is more common in TS.                 

16.    What is the approximate risk of malignancy if there is XY mosaicism in TS?

17.    How common is webbing of the neck in TS?                       

18.    How common is a low occipital hairline in TS?                    

19.    How common is congenital heart disease in TS?     

20.    Dissecting aortic aneurysm is more common in TS.

21.    How common is lymphoedema in TS?                    

22.    How common is kidney disease in TS?                   

23.    Short stature in TS has been linked to the TS gene. 

24.    What % of adolescents with TS have scoliosis.       .

25.    Inverted nipples are more common in TS.               

26.    1ry. amenorrhoea occurs in all cases.                     

27.    Adrenarche occurs at a normal time.                       

28.    Cubitus valgus is more common in TS.                   

29.    Cleft palate if a feature of TS.                                

30.    Micrognathia is a feature of TS.                             

31.    Abnormalities of teeth and nails are more common in TS.    

32.    Otitis media is more common in TS.                                   

33.    Intelligence is usually lower in TS, especially verbal skills.   

34.    Women with TS have higher mortality rates than other women..

35.    Oestrogen should be started on diagnosis to promote bone growth.  .

36.    Oestrogen-only HRT is appropriate for bone protection.      

37.    Women with TS have an ↑ risk of hypertension.      

38.    Women with TS have an ↑ risk of coeliac disease.  

39.    Women with TS have an increased risk of Crohn’s disease and ulcerative colitis. 

40.    Women with TS have an ↑ risk of diabetes              

41.    Women with TS have an ↑ risk of hyperthyroidism.  

42.    Women with TS have an ↑ risk of deafness. .

43.    Women with TS have an ↑ risk of osteoporosis.

44.    Women with TS have similar rates of red-green colour blindness as men.  

45.    Women with TS have a normal incidence of ptosis. 

46.    Women with TS cannot have children.

47.    The “short stature homeobox” (SHOX) gene has been implicated in TS

                

Tutorial 28 January 2013

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Essays 28 January 2013.

16           EMQ. Parvovirus.            

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      

A 30-year-old woman para 1+1 presents at 34 weeks gestation with right loin pain, frequency of micturition, dysuria and pyrexia.

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

2. Justify the investigations you will arrange.  6 marks.

3. Justify your management.                       12 marks. 

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.              

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.               

Lead-in.

The following scenarios relate to parvovirus infection

Pick one option from the option list.

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

Abbreviations.

GOVRIP:        Guidance on Viral Rash in Pregnancy. HPA. 2011

                         http://www.hpa.org.uk/webc/HPAwebFile/HPAweb_C/1294740918985

HPA:               Health Protection Agency

PSVMCA:      peak systolic velocity middle cerebral artery.

PvB19:            parvovirus B19

PvIgG:            parvovirus B19 IgG

PvIgM:           parvovirus B19 IgM

Option list.

There is none: make up your own answers!

Scenario 1.

What type of virus is parvovirus?

Scenario 2.

Is the title B19 something to do with the American B19 bomber, its potentially devastating bomb load and the comparably devastating consequences of the parvovirus on human erythroid cell precursors?

Scenario 3.

PVB19 in the UK occurs in mini-epidemics at 3 – 4 year intervals, usually during the summer months.

Scenario 4.

Which animal acts as the main reservoir for infection?

Scenario 5.

What percentage of UK adults are immune to parvovirus infection?

Scenario 6.

What names are given to acute infection in the human?

Scenario 7.

What is the incubation period for parvovirus infection?

Scenario 8

What is the duration of infectivity for parvovirus infection?

Scenario 9.

What are the usual symptoms of parvovirus infection in the adult?

Scenario 10.

What is the incidence of parvovirus infection in pregnancy?

Scenario 11.

How is recent infection diagnosed?

Scenario 12.

How long does PvIgM persist and why is this important?

Scenario 13.

What is the rate of vertical transmission of parvovirus infection?

Scenario 14.

Are women with parvovirus infection who are asymptomatic less likely to pass the virus to their fetuses?

Scenario 15.

To what degree is parvovirus infection teratogenic?

Scenario 16.

What proportion of pregnancies infected with parvovirus are lost?

Scenario 17.

What is the timescale for the onset of hydrops?

Scenario 18.

Laboratories are advised to retain bloods obtained at booking for at least 2 years for possible future reference. True or false?

Scenario 19.

What ultrasound features would trigger consideration of cordocentesis?

Scenario 20.

Must suspected parvovirus infection be notified to the authorities?

Scenario 21.

Possible parvovirus infection does not need to be investigated after 20 week’s gestation.

Scenario 22

If serum is sent to the laboratory from a woman with a rash in pregnancy for screening for rubella, the laboratory should automatically test for parvovirus infection too.

24th. January 2013

No one came for the tutorial tonight, so there was no tutorial.

21 January 2013

Tutorial.  https://soundcloud.com/drtmcf/21-january-2013
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Essays 21^st. January 2013.

1. You are the SpR in the antenatal clinic. The consultant is absent due to illness and no other consultant is available. A midwife asks you to see a woman whose scan has shown anencephaly.

1. What steps will you take before seeing the woman?         6 marks

2. Justify the approach you will use during the interview.     10 marks

3. What will you do when the interview is over?                   4 marks         

2. Question. Critically evaluate HPV vaccine and its uses.           

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.      

4. A 25 year-old woman books at 8 weeks. She has one child, aged 3 years. He has recently had chickenpox diagnosed. Her sister is 38 weeks pregnant.

1.  Justify your initial management.                                     8 marks.

2.  Justify your management for the rest of the pregnancy.  8 marks.

3.  Justify the advice you will give with regard to her sister.  4 marks.        

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?

Tutorial 17 January 2013

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Tonight we had five essays, two of them similar.
And confusion over the EMQs.
I e-mailed one on Hepatitis B, only to be told that we had done it already.
It is in the tutorial for the 13th. December, so look there if you have not done it.
I added one on maternal death definitions - these can be tricky.
The essays were:

1.      Critically evaluate neonatal screening.

2.      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.

3.      A nulliparous woman is found to have hydrops fetalis on a routine 20 week anomaly scan.

1. List the main causes of hydrops fetalis.      12 marks.

2. Outline the key investigations.                        8 marks.

4.      46  A woman of 48 is referred with erratic vaginal bleeding for six months. She has had an IUCD 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

5.      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.

Essays 1 & 2 have not featured in the exam. There have been a lot of changes in neonatal screening and I think it would make a good topic. Neonatal topics are legitimate and I am surprised that jaundice has not featured.

Hydrops fetalis came in 1998, but not since and, I am sure, will return one day. It is a technical essay, so you need a model.

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:  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”?

14 January 2013

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Tonight we had one EMQ and four essays.

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.     

With regard to pertussis and pregnancy.

1. What is pertussis caused by, how is it spread and 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.              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.

Your consultant is on leave. The Secretary gives you an 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.       

With regard to epidural anaesthesia:

1. Outline the main differences between it and spinal anaesthesia. 4 marks.

2. Outline the main techniques and drugs used.                           6 marks.

2. Evaluate the main contraindications.                                        4 marks.

3. Discuss the main uses.                                                          6 marks.

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

10 January 2013

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Tonight we had the privilege of the company of Varsha Mulik.
She was a consultant in the UK, but has been in Singapore for the past couple of years doing high-powered ultrasound.
She runs the North West MRCOG Written course, which has been taking place this week.
I felt that having her in the country was too good an opportunity to miss, so I decided we should have a couple of essays that played to her expertise.
The essays we discussed were:

1. 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.

2. With regard to cell-free fetal DNA (cffDNA).

a.      what is cffDNA?                                                      4 marks

b.     detail the current uses of cffDNA in the NHS.            6 marks

c.      discuss the potential uses of cffDNA.                        10 marks

3. Critically evaluate Down’s syndrome screening.

We then had two EMQs.

Obstetric cholestasis. (OC). 1.

Lead-in.

The following scenarios relate to the prevalence of OC.

Pick one option from the option list.

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

Abbreviations.

GTG:     RCOG’s Green-top Guideline No. 43. April 2011.

OC:        obstetric cholestasis.

Option list.

A.        0.1%

B.        0.5%

C.        0.7%

D.        1 – 1.2%

E.         1.2% to 1.5%

F.         1.5 – 2%

G.       2.4%

H.        3 – 3.5%

I.          5%

J.          7%

K.        15%

L.         white

M.      brown

N.       blue-green

O.       red-brown, striped

P.        no information in the GTG

Q.       none of the above

Scenario 1.

What is the overall prevalence in the UK population?

Scenario 2.

What is the overall prevalence in the Indian and Pakistani Asian populations?

Scenario 3.

What is the overall prevalence in Scandinavia?

Scenario 4.

What is the overall prevalence in Chile?

Scenario 5.

What is the overall prevalence in Araucanian Indians?

Scenario 6.

What is the overall prevalence in Eskimos?

Scenario 7.

What is the incidence of pruritus in pregnancy?

Scenario 8.

What colour of eggs do Araucanian chickens lay?

Obstetric cholestasis. (OC). 2.

Lead-in.

The following scenarios relate to the definition and diagnosis.

Pick one option from the option list.

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

Some of the answers are more MCQ than EMQ, i.e. “true” or “false”.

Abbreviations.

gamma GT: gamma-glutamyl transferase

GTG:      RCOG’s Green-top Guideline No. 43. April 2011.

OC:         obstetric cholestasis.

Suggested reading.

The GTG is “must read”.  It is also dealt with in MCQ paper 1, question 41. I don’t think you need to read anything more.

Option list.

A.             true

B.             false

C.             don’t be daft

D.             pruritus of pregnancy with no other explanation which is associated with abnormal LFTs, raised bile acids and pale stools, all of which resolve postnatally

E.              pruritus of pregnancy with no other explanation which is associated with abnormal LFTs, ± raised bile acids and pale stools, all of which resolve postnatally

F.              pruritus of pregnancy with no other explanation which is associated with abnormal LFTs, ± raised bile acids, all of which resolve postnatally

G.            pruritus of pregnancy with no other explanation which is associated with abnormal LFTs (using pregnancy-specific ranges), ± raised bile acids and pale stools, all of which resolve postnatally

H.             pruritus of pregnancy with no other explanation which is associated with abnormal LFTs (using pregnancy-specific ranges), ± raised bile acids, all of which resolve postnatally

I.               levels do not usually rise in pregnancy

J.               mostly originates in the placenta

K.             levels vary with the time of day

L.              no information in the GTG

M.           none of the above

Scenario 1.

The international definition of OC was agreed at a conference in Tokyo in 1985.

Scenario 2.

What is the GTG’s definition of OC?

Scenario 3.

What is the incidence of pruritus in pregnancy?

Scenario 4.

Hepatitis B and C, but not hepatitis A, may cause pruritus and abnormal LFTs in pregnancy.

Scenario 5.

Infection with the Ebstein Barr virus may cause pruritus and abnormal LFTs in pregnancy.

Scenario 6.

The cytomegalovirus may cause pruritus and abnormal LFTs in pregnancy.

Scenario 7.

The herpes zoster virus may cause pruritus and abnormal LFTs in pregnancy.

Scenario 8.

Chronic active hepatitis and secondary biliary cirrhosis are included in the GTG’s list of conditions to be considered in the differential diagnosis.

Scenario 9.

Bilirubin levels are normally elevated in the early stages of OC and remain elevated until the condition resolves after delivery.

Scenario 10.

Liver function tests become abnormal as soon as the pruritus is noted.

Scenario 11.

Levels of bile acids commonly rise significantly after meals making fasting levels mandatory for diagnosis.

Scenario 12.

The upper limit of normal for transaminases, gamma GT and bile acids is about 20% lower in pregnancy.

Scenario 13.

Once a diagnosis of OC has been made, tests of liver function should not be repeated until the puerperium

Scenario 14.

LFTs should be checked weekly until they have returned to normal after delivery of the baby in a case of OC.

Scenario 15.

Once a diagnosis of OC has been made, the activated partial thromboplastin time (APTT) should be measured and a full coagulation screen done if it is prolonged.

Scenario 16.

Delivery at 37 weeks should be recommended because of the risk of FDIU in the later weeks of pregnancy.

Scenario 17.

What additional pre-labour monitoring of fetal welfare is advisable in the third trimester?

Scenario 18.

Prophylactic steroids should be offered at 28 weeks because of the risk of spontaneous premature labour.