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We will start with OSCE tutorials on the Monday after the exam: 10th. March.
25
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EMQ. Diabetes
in pregnancy
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26
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EMQ. Ectopic
pregnancy
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27
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EMQ. Epidural
anaesthesia
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28
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EMQ. Gp B
Streptococcal infection
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29
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EMQ. Germ cell and sex cord tumours
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30
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EMQ. Puerperal
mental illness
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91
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With regard to blood transfusion in
obstetrics:
1. outline the main hazards
of blood transfusion.
2 mark
2. how may the incidence of
transfusion be reduced?
3 marks
3. outline the key issues
relating to red cell use. 4 marks
4. critically evaluate cell
salvage.
4 marks
5. critically evaluate the
use of fresh frozen plasma. 3 marks
6. critically evaluate the
use of platelets.
2 marks
7. critically evaluate the
use of recombinant factor VIIa.
2 marks
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92
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A nulliparous woman
notices reduced fetal movements at 37 weeks and phones the delivery unit for
advice.
1. Outline
the immediate management. 14 marks
2. Justify
the subsequent management. 6
marks.
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Diabetes in pregnancy.
Lead-in.
The following scenarios relate to diabetes
in pregnancy.
For each, select the action from the
option that best fits the scenario.
Pick one option from the option list.
Each option can be used once, more than
once or not at all.
Abbreviations.
ACE: angiotensin
converting enzyme.
ARA: angiotensin
II receptor antagonist.
GDM: gestational
diabetes mellitus.
OGTT: oral
glucose tolerance test.
Option list.
A. advise postponement of pregnancy.
B. normal antenatal care.
C. refer to a joint diabetic / antenatal
clinic.
D. refer to the next joint diabetic /
antenatal clinic.
E. refer for a diabetic opinion.
F. refer to a nephrologist.
G. refer to a clinical psychologist.
H. arrange referral for screening for
diabetic retinopathy.
I.
screen
for microalbuminuria.
J.
stop ACE
inhibitor / ARA drugs and arrange for safer substitutes.
K. advise to continue statin.
L. asvise to stop statin.
M. prescribe folic acid 5mg. daily and advise
HbA1c , 6.1%, if not associated with untoward symptoms.
N. stop oral hypoglycaemic drug and start
insulin.
O. discuss pros and cons of oral
hypoglycaemic drug, but allow her to continue to take it.
P. arrange fasting plasma glucose level and
repeat monthly.
Q. arrange HbA1c assay and repeat monthly.
R. arrange a 75 gram OGTT now.
S. arrange a 75 gram OGTT at 16 weeks
T. arrange a 75 gram OGTT at 28 weeks.
U. arrange a 100 gram OGTT now.
V. arrange a 100 gram OGTT at 16 weeks
W. arrange a 100 gram OGTT at 28 weeks.
X. Resign, buy a yacht and sail to Bali.
Y. none of the above
Scenario 1.
A woman with type II diabetes
attends for pre-pregnancy counselling. Her HbA1c is 10.6 %. Her health is good.
She last had screening for retinopathy 8 months ago. What is the most important
advice you will give?
Scenario 2.
A woman with type II diabetes
attends for pre-pregnancy counselling. Her HbA1c is 5.4 %. She last had
screening for retinopathy 8 months ago. What advice will you give about
retinopathy screening?
Scenario 3.
A 35 year-old para 1 with type
II diabetes attends for pre-pregnancy counselling. Her health is good. Her
HbA1c is 4.8%. Her pregnancy was 2 years ago and was normal. The baby weighed
3.5 kg. at 40 weeks and is healthy. Her serum creatinine is 125 micromol/
litre.
Scenario 4.
A 35 year-old para 1 with type II diabetes
attends for pre-pregnancy counselling. Her health is good. Her HbA1c is 4.8%.
Her pregnancy was 2 years ago and was normal. The baby weighed 3.5 kg. at 40
weeks and is healthy. Her GFR is 60 ml./minute. What advice will you give about
referral to a nephrologist?
Scenario 5.
A 35 year-old para 1 with type II diabetes
attends for pre-pregnancy counselling. Her health is good. Her blood sugar
levels are well controlled with diet and metformin. What advice will you give
about metformin?
Scenario 6.
A 38 year-old woman attends
the booking clinic at 8 weeks. GDM was diagnosed at 34 weeks in the 1st.
pregnancy. Despite good glycaemic control, the baby weighed 5.2 kg. and
required Caesarean section for delivery after a prolonged 2nd.
stage. She is keen to have the earliest possible diagnosis of recurrence.
Scenario 7
A 38 year-old woman attends
the booking clinic at 8 weeks. GDM was diagnosed at 34 weeks in the 1st.
pregnancy. Despite good glycaemic control, the baby weighed 5.2 kg. and
required Caesarean section for delivery after a prolonged 2nd.
stage. She is keen to have the earliest possible diagnosis of recurrence but
has needle phobia and an aversion to self-monitoring.
Scenario 8
A 25-year-old primigravida
books at 10 weeks. Her health is good but her BMI is 28. What screening for
hyperglycaemia will you arrange.
Scenario 9
A healthy para 1 books at 10
weeks. She takes a statin because of elevated cholesterol and triglyceride
levels. Her blood pressure is 130/85. Otherwise she is well.
Ectopic & early pregnancy. NICE CG154.
Lead-in.
The following scenarios relate to ectopic
and early pregnancy.
Some of the questions are MCQs, with
“True” or “False”, not EMQs.
Some want you to write a list of facts.
There is no option list – write what you
think the answer should be.
Abbreviations.
APH: antepartum
haemorrhage.
EPU: early
pregnancy unit.
GIT: gastro-intestinal
tract.
PUL: pregnancy
of unknown location.
SB: stillbirth.
SML: “Saving Mothers’
Lives.” March 2011. The
8th. Report of the Confidential Enquiries into Maternal Deaths in
the UK.
Suggested
reading.
Scenario 1.
NICE endorses the view of the
authors of SML that the term “PUL” should no longer be used.
Scenario 2.
Early pregnancy is defined by
in CG154 as pregnancy in the first trimester, i.e. up to 12 completed weeks.
Scenario 3.
What % of early pregnancies miscarry?
Scenario 4.
What is the rate of ectopic pregnancies
per 1,000 pregnancies?
Scenario 5.
What is the mortality rate per 1,000
ectopic pregnancies?
Scenario 6
List the key things CG154 has
about “support and information-giving”.
Scenario 7
Each Trust should ensure that
its EPU is accessible every day.
Scenario 8
What communications training should
professional staff have had?
Scenario 9
Non-clinical staff should be selected on
the basis of being old, plain or, even better, ugly, so that women with
pregnancy problems do not feel threatened by the presence of beautiful young
women.
Scenario 10
All women with early pregnancy problems
should be able to access EPUs directly and not through a health professional
such as their GP.
Scenario 11
Women with miscarriage should
be offered expectant management for 7 – 14 days as the first-line option.
Scenario 12
CTG 154 picks out late 1st.
trimester gestation as a risk factor for bleeding.
Scenario 13
List the common clinical presentations of
ectopic pregnancy that may mislead the unwary diagnostician.
Scenario 14
Surgical evacuation should be done under
general anaesthesia or regional block, either epidural or spinal.
Scenario 15
Surgical treatment for ectopic pregnancy
should be laparoscopic as far as possible.
Scenario 16
Salpingectomy and salpingectomy are equivalent
in the management of ectopic pregnancy and should be offered according to the
experience and preference of he surgeon.
Scenario 17
What proportion of women are likely to
need further treatment after salpingostomy?
Scenario 18
When should women have hCG testing after
salpingostomy?
Scenario 19
When should women have hCG testing after
salpingectomy?
Scenario 20
When should anti-D be given and in what
dose?
Scenario 21
When should a Kleihauer test be done?
Epidural anaesthesia.
Lead-in.
The following scenarios relate to epidural
anaesthesia.
For each, select the answer that best fits
the scenario.
Pick one option from the option list.
Each option can be used once, more than
once or not at all.
Scenario 1.
Which spinal level(s) conduct
pain sensation from the uterus and cervix?
Scenario 2.
Which spinal level(s) conduct
pain from the perineum?
Scenario 3.
Which spinal level(s) conduct
pain from the left big toe and what does it signify?
Scenario 4.
Maternal pyrexia is a complication of
epidural anaesthesia.
Scenario 5.
Spinal anaesthesia is effective more
rapidly than epidural anaesthesia.
Scenario 6.
Adding an opioid to the local
anaesthetic drug increased the potency of epidural anaesthesia.
Scenario 7
Epidural anaesthesia increases
the Caesarean section rate.
Scenario 8
Epidural anaesthesia increases
the length of labour.
Scenario 9
What is the rate of incomplete
block with epidural anaesthesia?
Option list.
A. True
B. False
C. ≥ 1 in 10
D. 1 in 10 to 1 in 100.
E. 1 in 100 to 1 in 1,000
F. 1 in 1,000 to 1 in 50,000
G. 1 in 50,000 to 1 in 100,000
H. 1 in 100,000 or less
I.
T8 - T12
J.
T10 – L1
K. L2 - L8.
L. L8 - S1
M. S1 – S4
N. S2 – S4
O. S3 – S5
P. 10%
Q. 20%
R. 20 – 50%
S. 50 – 70%
T. 80 – 90%
U. 90 – 100%
V. I have no idea, I don’t care and I am going to the pub
to drown my sorrows!
W. None of the above.
Group B Streptococcus.
Lead-in.
The following scenarios relate to Group B
Streptococcal disease.
Pick one option from the option list.
Each option can be used once, more than
once or not at all.
Abbreviations.
Cochrane: Cochrane
Database Systematic Review 2009(3):CD007467.
EOGBS: early-onset
GBS disease.
GBS: Group
B streptococcus.
GTG: GTG36.
2012. ”The Prevention of Early-onset Neonatal Group B
Streptococcal Disease”.
IAP: intrapartum antibiotic
prophylaxis.
Suggested
reading.
Any question will be derived from the GTG,
so make sure you know it well.
Option list.
1. Streptococcus agaractiae
2. Streptococcus intergalacticae
3. Streptococcus agalactiae
4. Streptococcus ubernastiae
5. Lancelot
6. Lanceforth
7. Lanceford
8. Landscape
9. 0.01%
10. 0.02%
11. 0.023%
12. 0.025%
13. 0.05%
14. 0.1%
15. 0.5%
16. 0.53%
17. 0.54%
18. 0.6%
19. 0.63%
20. 0.75%
21. 0.9%
22. 1%
23. 2%
24. 2.3%
25. 2.4%
26. 2.5%
27. 5%
28. 10%
29. 15%
30. 20%
31. 25%
32. 26.3%
33. 21%
34. 30%
35. 35%
36. 1
37. 2
38. 3
39. 5
40. 6
41. 9
42. 10
43. True
44. False
45. you are driving me mad with all these percentages
Scenario 1.
What is the scientific name
for GBS?
Scenario 2.
Which animal is the main
reservoir for GBS?
Scenario 2.
What system is used for
grouping streptococci?
Scenario 3.
Where does GBS disease feature
in the list of serious early-onset neonatal infection?
Scenario 4.
What is the upper limit in
days for time of onset in the definition of “early-onset” disease?
Scenario 5.
GBS is a gram-negative,
capsulated organism.
Scenario 6.
What is the incidence of EOGBS
in the UK in the babies of women who have not been screened for GBS or had IAP?
Scenario 7
What is the incidence of EOGBS
in the babies of American women who have had antenatal GBS screening and IAP if
screen+ve?
Scenario 8
What is the mortality rate of
EOGBS in the UK?
Germ cell and sex cord tumours and substances secreted.
Lead-in.
The following scenarios relate to the
substances that ovarian cell tumours usually secrete.
For each, select the most appropriate
substance from the option list.
Each option can be used once, more than
once or not at all.
Option List.
A. None.
B. a-fetoprotein.
C. a-fetoprotein + hCG.
D. a1-antitrypsin
E. Androgen.
F. Ascites.
G. Walthard
H. Ca125
I.
hCG.
J.
β-hCG
K. Follicle stimulating hormone.
L. Luteinising hormone.
M. Oestrogen.
N. Prolactin.
O. Thyroxine sufficient to produce hyperthyroidism.
P. Pleuritic fluid.
Q. None of the above.
Scenario 1.
Mature cystic teratoma.
Scenario 2.
Granulosa cell tumour.
Scenario 3.
Sertoli-Leydig tumours.
Scenario 4 .
Brenner tumour.
Scenario 5.
Struma ovarii.
Scenario 6.
Embryonal carcinoma.
Scenario 7.
Polyembryoma.
Scenario 8.
Endodermal sinus tumour (Yolk
sac tumour).
Scenario 9.
Dysgerminoma.
Scenario 10.
Primary ovarian
choriocarcinomas.
Scenario 11.
Dysgerminoma.
Puerperal Mental Illness.
Lead-in.
The following scenarios relate to puerperal mental illness.
Pick one option from the option list.
Each option can be used once, more than once or not at all.
If I had put all the answers into the option list it would have
been enormous. So there are quite a few where you need to decide what your
answer would be. Opting for “none of the above” is not exercising your brain –
make sure you come up with an answer.
Option list.
a.
arrange admission to hospital
under Section 5 of the Mental Health Act
b.
send a referral letter to the
perinatal psychiatrist requesting an urgent appointment.
c.
send an e-mail to the perinatal
psychiatrist requesting an urgent appointment.
d.
phone the community psychiatric
team.
e.
phone the on-call psychiatrist.
f.
arrange to see the patient in the
next ante-natal clinic.
g.
arrange to see the patient
urgently.
h.
send a referral letter to the
social services department.
i.
phone the fire brigade.
j.
phone the police.
k.
there is no such thing.
l.
4 weeks
m.
6 weeks
n.
12 weeks
o.
26 weeks
p.
1 year
q.
<1%
r.
1-5%
s.
5-10%
t.
10-20%
u.
25%
v.
50%
w.
60%
x.
70%
y.
80%
z.
True
aa.
False
bb.
none of the above.
Scenario 1
What is the internationally agreed classification for
postpartum psychiatric disease?
Scenario 2
What time limits does DSM-IV use for postpartum
psychiatric disorders?
Scenario 3
What time limits does ICD-10 use pro postpartum
psychiatric disorders?
Scenario 4
What clinical classification would you use in a viva
or SAQ?
Scenario 5
What is the incidence of suicide in relation to
pregnancy and the puerperium?
Scenario 6
What are the main conditions associated with suicide
in pregnancy and the postnatal period?
Scenario 7
Most suicides occur in single women of low social
class who have poor education. True / False
Scenario 8
The preferred method of suicide reported in the MMR
was drug overdose. True / False.
Scenario 9
When are women with Social Services involvement
particularly at risk of suicide.
Scenario 10
Which women have the highest risk for puerperal
psychosis and what is the risk?
Scenario 11.
What is the risk of puerperal psychosis for a
primigravida with BPD?
Scenario 12
What is the risk of PP in a woman with no history of
psychiatric illness but who has a FH of PP?
Scenario 13
Should screening include the identification of women
with no history of psychiatric illness but who has a FH of PP?
Scenario 14
What do the Confidential
Enquiries into Maternal Deaths say about the use of the term “postnatal
depression”?
Scenario 15
Women with schizophrenia have a ≥ 25% risk of
puerperal recurrence. True / False
Scenario 16
If lithium therapy for BPD is stopped in pregnancy,
there is an increased risk of severe puerperal illness. True / False.
