Sunday 23 February 2014

20 February 2014

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This was the last tutorial before the written exam.
We will start with OSCE tutorials on the Monday after the exam: 10th. March.




25
EMQ. Diabetes in pregnancy
26
EMQ. Ectopic pregnancy
27
EMQ. Epidural anaesthesia
28
EMQ. Gp B Streptococcal infection
29
EMQ. Germ cell and sex cord tumours
30
EMQ. Puerperal mental illness
91
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
92
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.

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.
CG154: NICE Clinical Guideline 154, December 2012. “Ectopic pregnancy and miscarriage.”
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.
 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.



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