Tutorial 4 December 2014

4 December 2014.

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1.	How best to get the group to write SBAs and EMQs
2.	EMQ. Parvovirus & pregnancy.
3.	EMQ. Mental Capacity Act.
4.	SBA. Recurrent miscarriage.
5.	MgSO4 : what points might feature in the exam? SIP 29.
6.	EMQ. Early pregnancy complications. Diagnoses to exclude.
7.	Communication skills. How to make a start.

2. Parvovirus.

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.

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?

3. Mental Capacity Act.

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?

Scenario 10

An 8 year old girl is admitted with abdominal pain. Appendicitis is diagnosed with peritonitis and surgery is advised. The parents decline treatment on religious grounds. Can the consultant in charge overrule the parents and give consent?

4. Recurrent miscarriage.

Author: Selvambigai Raman.

Abbreviations.

EPAS:            early pregnancy assessment service.

EPU:              dedicated early pregnancy assessment unit.

GDG:             guideline development group.

GGT:              Gamma-glutamyl transferase.

GTD:              gestational trophoblastic disease.

NK:                natural killer.

PCOS:            polycystic ovary syndrome.

PIGD:            pre-implantation genetic diagnosis.

PIGS:             pre-implantation genetic screening.

RM:               recurrent miscarriage.

TORCH:         Toxoplasmosis, rubella, cytomegalovirus & herpes. (Other definitions include HIV, syphilis and other infections.) Fortunately, TORCH screening is out-of-date, exact definitions are not important, though I’d stick with the first if asked.

UA:                uterine anomaly.

Question 1.

Lead-in

In relation to miscarriage, which, if any, of the following statements are correct?

1. the term “spontaneous miscarriage” is really stupid
2. most miscarriages are genetic in causation.
3. most women who miscarry do not get a diagnosis of causation
4. the majority of women have significant levels of psychological distress after miscarriage.
5. counselling is of significant benefit in reducing levels of psychological distress after miscarriage.

Option List

A.	i + ii
B.	i + ii + iii
C.	i + ii + iii + iv
D.	i + ii + iii + v
E.	i + ii + iii + iv + v

Question 2.

Lead-in

Which of the following statements are true.

1. miscarriage occurs in 11% of women with age 20-24 years
2. miscarriage occurs in 25% of women with age 35-39 years
3. miscarriage occurs in > 90% of mothers with age ≥ 45 years
4. recurrent miscarriage affects about 1% of couples
5. recurrent miscarriage affects about 5% of couples

Option List

A.	i + ii
B.	i + iii
C.	i + ii + iv
D.	i + iii + v
E.	i + ii + iii + iv

Question 3.

Lead-in

What figure is usually given for the overall incidence of miscarriage?

Option List

A.	< 10 %
B.	10 - 20%
C.	20 - 25%
D.	25 – 30 %
E.	>30%

Question 4.

Lead-in

A healthy, 26-year-old, woman attends the booking clinic at 6 weeks in her first pregnancy. A pregnancy test is +ve. Her best friend recently had an early miscarriage. What risk will you quote?

Option List

A.	≤ 5%
B.	5 – 10%
C.	10 – 15%
D.	15 – 20%
E.	≥ 20%

Question 5.

Lead-in

The same healthy woman attends the ANC at 8 weeks for a dating scan. Before she has the scan she asks you what her risk is now. She has had no abnormal symptoms. What risk will you quote?

Option List

A.	≤ 5%
B.	5 – 10%
C.	10 – 15%
D.	15 – 20%
E.	≥ 20%

Question 6.

Lead-in

The same healthy, nulliparous woman comes back to see you after the scan. The scan is normal and shows a viable fetus. She asks what her risk is now. What risk will you quote?

Option List

	≤ 5%
	5 – 10%
	10 – 15%
	15 – 20%
	≥ 20%

Question 7.

Lead-in

Pick the best option from the list below for the definition of RM.

Option List

	two or more miscarriages
B.	two or more miscarriages in healthy women
C.	three or more miscarriages
D.	three or more miscarriages in women with no children
E.	none of the above.

Question 8.

Lead-in

The following are possible causes of RM except for one. Pick the best option for the exception.

Option List

	increased maternal age
	maternal cigarette smoking
	maternal alcohol consumption
	exposure to anaesthetic gases
	exposure to emissions from video display terminals

Question 9.

Lead-in

A woman presents to antenatal clinic for booking at 6 weeks. She has a history of 3 RMs with no explanation found after full investigation. What is her risk of miscarriage in this pregnancy?

Option List

A.	≤ 10%
B.	20%
C.	25%
D.	50%
E.	75%

Question 10.

Lead-in

4) A 35-year-old woman with a history of 3 RMs presents to you for advice regarding the risk of miscarriage if she conceives. Pick the best option to describe her risk from the list below.

Option List

A.	20%
B.	30%
C.	40%
D.	50%
E.	55%

Question11.

Lead-in

The following statement relates to women with arcuate uteri.

There is evidence to suggest that women with arcuate uteri:

                i.     tend to miscarry more in first trimester

              ii.     tend to miscarry more in second trimester

            iii.     have no increased risk of miscarriage

            iv.     are at increased risk of cephalo-pelvic disproportion

              v.     are at increased risk of Caesarean section

Pick the best option from the list below.

Option List

A.	i
B.	i + v
C.	ii + iv
D.	ii + v
E.	iii + v

Question 12.

Lead-in

With regards to EPUs, which of the following statements, if any, are true.

         i.            all women with pain + bleeding in early pregnancy can self-refer to an EPU

       ii.            all women with pain + bleeding in early pregnancy should be seen by a health professional before referral to an EPU

     iii.            women with a history of ectopic pregnancy, molar pregnancy or recurrent miscarriage should be able to self-refer to an EPU

     iv.            women with a history of puerperal psychosis should be able to self-refer to an EPU

Option List

A.	i
B.	ii
C.	iii
D.	iv
E.	iii + iv

Question 13.

Lead-in

Which, if any, of the following investigations should be done for a couple with 1^st trimester RM?

         i.            APS screen

       ii.            Fragile X syndrome screen

     iii.            HbA1c

     iv.            hysterosalpingogram

       v.            inherited thrombophilia screen

     vi.            karyotyping

    vii.            NK cells in peripheral blood

  viii.            thyroid function tests

     ix.            TORCH screen

Option List

A.	i
B.	i +  v
C.	i + ii + v + vi + viii + ix
D.	i + iii + iv + v + vi + vii + viii + ix
E.	all of the above except vii

Question 14.

Lead-in

Which, if any of the following treatments should be offered to women with RM and evidence of APS?

Option List

i.	low-dose aspirin + clopidogrel
ii.	low-dose aspirin + LMWH
iii.	low-dose aspirin + LMWH + low-dose corticosteroids
iv.	low-dose aspirin + unfractionated heparin
v.	low-dose aspirin  + unfractionated heparin + low-dose corticosteroids

Question 15.

Lead-in

Which, if any, of the following treatments are of proven benefit in improving outcomes in unexplained RM?

         i.            cervical cerclage

       ii.            hCG

     iii.            leptin

     iv.            LH

       v.            metformin

     vi.            rectal or vaginal progesterone

    vii.            supportive therapy in a dedicated EPU

  viii.            PIGS

Option List

A.	i + ii
B.	i + vi + vii
C.	ii + vi + vii + vii
D.	vii
E.	none of the above

Question 16 .

Lead-in

With regard to the role of PIGS in the management of women with unexplained RM, which, if any, of the following statements are true.

         i.            PIGS is of proven benefit in unexplained RM

       ii.            PIGS is regulated by the HFEA

     iii.            PIGD and PIGS are different names for the same process

Option List

A.	i
B.	ii
C.	i + ii
D.	i + ii + iii
E.	none of the above

Question 17.

Lead-in

Pick the most appropriate option from the list below about the risk of miscarriage in women with PCOS and a history of RM who conceive spontaneously.

Option List

A.	increased serum LH levels predict an increased risk of miscarriage
B.	Increased testosterone levels predict an increased risk of miscarriage
C.	Decreased androgen levels predict an increased risk of miscarriage
D.	Typical PCOS ovarian morphology predicts an increased risk of miscarriage
E.	Hyperinsulinaemia predicts an increased risk of miscarriage

5. MgSO₄ & pregnancy.

Jot down all the facts you know about this subject that you think might be asked in the exam.

7. Communication skills. How to start developing skills now for the OSCE.