Tutorial 28 November 2013

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https://soundcloud.com/drtmcf/28-november-2013

Tonight we had an EMQ, 4 essay plans and a bit of a roleplay.

EMQ3. Parvovirus infection and pregnancy

Cytomegalovirus infection. A woman books at 8 weeks’ gestation in her first pregnancy. She is concerned because she works in a nursery where there has been an outbreak of cytomegalovirus infection. Critically evaluate the management.

Critically evaluate the “Top Ten Recommendations” in “Saving Mothers’ Lives”, The Eighth Report of the Confidential Enquiries into Maternal Deaths in the United Kingdom. 2006–2008.

Delayed cord clamping. A 25-year-old primigravida attends the antenatal clinic at 36 weeks. She has read a magazine article about delayed cord clamping. Critically evaluate the issues relating to delayed cord clamping.

With regard to anti-phospholipid syndrome: 1. outline the clinical manifestations of APS.        4 marks. 2. outline the implications of APS for pregnancy  4 marks. 3. critically evaluate how the diagnosis is made.   4 marks. 4. critically evaluate the management in the woman wishing to be pregnant.    8 marks.

Roleplay. Healthy, nulliparous woman referred for pre-pregnancy counselling. Brother has cystic fibrosis. You are asked to explain cystic fibrosis and the implications for her.

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?  Yes or No.

Scenario 21.

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

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.  True or false?

Tutorial 25 November 2013

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https://soundcloud.com/drtmcf/25-november-2013

Tonight we had an EMQ, 4 essays and a roleplay.
You might think it too early to start with roleplays, but you have lots of opportunities to practise in real life between now and next May.
There is advice about the basics of communication skills on the website:
http://www.drcog-mrcog.info/Topics%20not%20in%20the%20textbooks.htm.

The essays were:

3.	Discuss the key issues relating to the second trimester fetal anomaly ultrasound scan.
4.	Critically evaluate the uses of magnesium sulphate in obstetrics.
5.	Critically evaluate screening for gynaecological cancer
6.	COC. Discuss the non-contraceptive benefits

The EMQ was:

EMQ Paper 1, Question 1.

Lead-in.

The following scenarios relate to early pregnancy.

For each, select the diagnosis you most want to exclude.

Pick one option from the option list.

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

Scenario 1.

A 35-year-old primigravida is seen in the EPU with vaginal bleeding and severe left iliac fossa pain. The pregnancy occurred after four cycles of IVF and embryo transfer was performed six weeks ago. Her β-hCG is >1,000 iu/l. An ultrasound scan showed an intra-uterine pregnancy of an appropriate size for the gestation. Normal fetal heart activity was noted. No adnexal masses were seen.

Scenario 2.

A 25-year-old woman with known PCOS is seen in the early pregnancy unit after an episode of slight vaginal bleeding. Her LMP was 10 weeks ago. An ultrasound scan shows an intra-uterine pregnancy with CRL of 6 mm. No fetal heart activity is seen.

Scenario 3.

A GP phones for advice. She is conducting her morning surgery. A nulliparous woman at 6 weeks’ gestation has returned from France where she has enjoyed the local food, particularly unpasteurised soft cheese and pork meats. She has presented with diarrhoea and mild abdominal pain. A β-hCG is 25 iu/l. She is concerned about listeriosis and toxoplasmosis, about which she has read.

Scenario 4.

A 30-year-old parous woman attends the EPU with vaginal bleeding and lower abdominal pain. An ultrasound scan shows a 30 mm. intra-uterine sac but no evidence of fetal heart activity.

Scenario 5.

 A 45-year-old para 6 is admitted to the A&E department with 6 weeks’ amenorrhoea. A β-hCG is positive. She complains of retrosternal pain and has a history of heartburn and acid reflux. Her BMI is 30. She smokes 40 cigarettes daily and has COAD.

Option list.

Complete miscarriage.

Incomplete miscarriage.

Missed miscarriage.

Pregnancy in a uterine horn.

Ectopic pregnancy.

OHSS.

Ovarian torsion.

Ovarian cyst accident.

Hydatidiform mole.

Listeriosis.

Toxoplasmosis.

Crohn’s disease

Ulcerative colitis.

Duodenal ulceration.

Pulmonary embolism.

Pneumothorax.

Coronary thrombosis.

None of the above.

Tutorial 18 November 2013

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https://soundcloud.com/drtmcf/18-november-2013

Tonight we started with a discussion of how to prepare and the key things to do.
Then we had an EMQ and 3 SAQs.
Send your answers and I'll send mine.

Introduction.

How to prepare.

EMQ1.

Staging of cancer cervix.

1. Postmenopausal bleeding

A 55 year old woman is referred by her General Practitioner after a single episode of post-menopausal bleeding. Critically evaluate the management.

2. Obstetric Cholestasis.

1. Outline the symptoms and signs associated with OC.                                                  4 marks.

2. Critically evaluate the differential diagnosis of OC and the key investigations.               4 marks.

3. Outline the maternal and fetal risks of OC.                                                                  4 marks.

4. Justify your management of a case of OC diagnosed at 28 weeks.                               6 marks.

5. Outline the management of a woman with pruritus but normal results after full investigation at 30 weeks.                                                                                                                                       2 marks.

3. Audit.

You have been asked to perform an audit.

Outline the key issues involved in preparing and performing an audit.

EMQ Paper 1 , Question 6 . Ca Cx staging.

Lead-in.

The following scenarios relate to cervical cancer staging.

For each, select the most appropriate staging.

Pick one option from the option list.

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

Scenario 1.

A woman of 25 has a cone biopsy. The histology report shows squamous cell carcinoma penetrating to a depth of 2 mm and 6 mm in width. The resection margins are tumour-free. There is no evidence of spread outside the uterus. She is nulliparous and wishes to retain her fertility.

Scenario 2.

A woman of 25 has a cone biopsy. The histology report shows squamous cell carcinoma penetrating to a depth of 5 mm and 6 mm in width. The resection margins are tumour-free. There is no evidence of spread outside the uterus. She is nulliparous and wishes to retain her fertility.

Scenario 3.

A woman of 25 has a cone biopsy. The histology report shows squamous cell carcinoma penetrating to a depth of 5 mm and 6 mm in width. The resection margins are not tumour-free. There is no evidence of spread outside the uterus. She is nulliparous and wishes to retain her fertility.

Scenario 4.

A woman of 25 has a cone biopsy. The histology report shows squamous cell carcinoma penetrating to a depth of 6 mm and 3 cm in width. The resection margins are tumour-free. There is no evidence of extension outside the uterus. She is nulliparous and wishes to retain her fertility.

Scenario 5.

A woman of 25 has a cone biopsy. The histology report shows squamous cell carcinoma penetrating to a depth of 6 mm and 5 cm in width. The resection margins are tumour-free. She is nulliparous and wishes to retain her fertility.

Scenario 6.

A woman of 38 has a cone biopsy. The histology report shows squamous cell carcinoma penetrating to a depth of 4 mm and 6mm in width. The resection margins are tumour-free. An MR scan shows involvement of the lymphatic nodes in the left of the pelvis.

Scenario 7.

A woman of 45 has carcinoma of the cervix. It extends into the parametrium, but not to the pelvic side-wall. It involves the upper 1/3 of the vagina. There is MR evidence of para-aortic node involvement.

Scenario 8.

A woman of 55 has carcinoma of the cervix. It extends to the pelvic side-wall. It involves the upper 1/3 of the vagina. She has a secondary on the end of her nose.

Scenario 9.

A woman of 55 has carcinoma of the cervix. It involves the bladder mucosa.

Scenario 10.

A woman of 35 has a proven cancer of the cervix with extension into the right parametrium, but not to the pelvic side-wall. Left hydroureter and left non-functioning kidney are noted on IVP and there is no other explanation for the findings. Cystoscopy shows bullous oedema of the bladder mucosa.

Scenario 11.

A woman of 25 has a cone biopsy. It shows malignant melanoma. The lesion invades to a depth of 3 mm and is 5 mm in width. The margins of the biopsy are clear. There is evidence of lymphatic vessel involvement. There is no evidence of spread outside the uterus.

Option list.

Micro-invasive cervical cancer.

Stage Ia1

Stage Ia2

Stage Ia3

Stage Ib1

Stage Ib2

Stage Ib3

Stage IIa

Stage IIb

Stage IIc

Stage IIIa

Stage IIIb

Stage IIIc

Stage IVa

Stage IVb

Stage IVc

Stage Va

Stage Vb

Stage Vc

None of the above.

This question illustrates the problems surrounding staging. If you are not a cancer specialist, it is not something that you think about very often, if ever. So you have to put it into your list of things to revise in the days before the exam. If you haven’t started this list, do so now.