Tutorial 8 January 2015

Website.
Contact us.

30	EMQ. APH	8	January	2015
31	EMQ. Cervical smears & referral	8	January	2015
32	SBA.  Cowden syndrome	8	January	2015
33	SBA. PALB2 gene	8	January	2015
34	Communication	8	January	2015

30. Antepartum haemorrhage.

Lead-in.

The following scenarios relate to APH.

Pick one option from the option list.

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

Abbreviations.

ART:      assisted reproduction technology

FGR:      fetal growth restriction

GTG:     Green-top guideline no 62

PET:       pre-eclampsia

Option list.

A.      genital tract bleeding ≥ 500 ml. from 24 weeks until the delivery of the baby

B.      genital tract bleeding ≥ 500 ml. from 24 weeks until the delivery of the placenta.

C.      genital tract bleeding ≥ 500 ml. from 24 weeks, or earlier if the baby is live-born, until the delivery of the baby.

D.      1

E.       2

F.       3

G.      4

H.      5

I.        6

J.        7

K.       8

L.       9

M.    10

N.      15

O.     20

P.       30

Q.     50

R.      100

S.       500

T.       1,000

U.      true

V.      false

W.    none of the above

Scenario 1.

What is the definition of APH?

Scenario 2.

What is the upper limit in ml. for minor APH?

Scenario 3.

What is the upper limit in ml. of major haemorrhage?

Scenario 4.

What is the % risk of recurrence after 1 abruption?

Scenario 5.

What is the % risk of recurrence after 2 abruptions?

Scenario 6.

What is the major risk factor for placental abruption?

Scenario 7

List 10 risk factors for placental abruption.

Scenario 8

List 6 risk factors for placenta previa.

Scenario 9

In what % of pregnancies does APH occur?

Scenario 10

With regards to steps that can be taken to reduce the incidence of APH, what things would you include in an essay?

31. Cervical smear management.

Lead-in.

There are too many scenarios and the option list is too long. And some of the “scenarios” are really MCQs. Don’t tell me – I know! I have tried to think of all the questions that could arise. At some point I’ll chop it into several bits to make the option list more sensible. A smaller option list would also allow me to introduce more “tempters” that sound as though they should be the correct answer. Send your answer and I’ll send mine.

The following scenarios relate to the management of cervical smears.

Pick one option from the option list.

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

Abbreviations.

ALOs:            actinomyces-like organisms

BSCCP           British Society for Colposcopy and Cervical Pathology. http://www.bsccp.org.uk/

CIN:               cervical intraepithelial abnormality

CGIN:            cervical glandular intraepithelial abnormality

FSRH:            Faculty of Sexual and Reproductive Health: http://www.fsrh.org/

GUM clinic:  genito-urinary medicine clinic

LBC:               liquid-based cytology

LLETZ:           large loop excision of the transformation zone

NEC:              normal endometrial cell

NHSCSP:       NHS Cervical Screening Programme: http://www.cancerscreening.nhs.uk/cervical/

                       http://www.cancerscreening.nhs.uk/cervical/index.html

POP:              progesterone-only Pill

TZ:                 transformation zone

Option list.

a.         repeat the test

b.         repeat the test after 6 months

c.          repeat the test at 6 and 12 months

d.         repeat the test at 6 and 12 months and then annually until she has had 10 years’ follow-up followed by repeat tests at the normal intervals for her age

e.         repeat the test after 3 or 5 years according to her age as per routine follow-up

f.          repeat the test after HPV testing

g.         repeat the test after giving an appropriate antibiotic

h.         repeat the test after removing her IUCD.

i.           repeat the test after removing the IUCD and giving an appropriate antibiotic

j.           repeat the test after treating the TZ with diathermy

k.         repeat the test after treating the TZ with cryocautery

l.           discharge from follow-up

m.       refer for colposcopy

n.         refer for colposcopy within 2 weeks

o.         refer for colposcopy within 8 weeks

p.         refer for colposcopy within 12 weeks

q.         refer for colposcopy only if she has other significant signs or symptoms

r.          refer for cone biopsy

s.          refer for fractional curettage

t.          refer for “see and treat” LLETZ

u.         refer to GUM clinic

v.         recommend that she go back to America

w.       there is insufficient information to formulate a management plan

x.         false

y.         true

z.          none of the above

Scenario 1.

A woman with no previous abnormal smears has a routine smear showing an inadequate sample . What management will you suggest?

Scenario 2.

A woman with no previous abnormal smears has had a smear showing borderline nuclear changes.  What management will you suggest?

Scenario 3.

A woman with no previous abnormal smears has had a smear showing borderline nuclear changes. Cervical ectopy is noted.  What management will you suggest?

Scenario 4.

A woman with no previous abnormal smears has had a smear showing borderline cells of endocervical origin. What management will you suggest?

Scenario 5.

A woman with no previous abnormal smears has had a smear showing inflammatory changes.  What management will you suggest?

Scenario 6.

A woman with no previous abnormal smears has had a smear showing  inflammatory changes and ALOs. What management will you suggest?

Scenario 7.

A woman with no previous abnormal smears has had a smear showing  inflammatory changes. She takes the COC for contraception. What management will you suggest?

Scenario 8.

A woman with no previous abnormal smears has had a smear showing  inflammatory changes. She has a copper IUCD. What management will you suggest?

Scenario 9.

A woman with no previous abnormal smears has had a smear showing  inflammatory changes and ALOs. She has had hysteroscopic sterilisation with ESSURE. What management will you suggest?

Scenario 10

A woman with no previous abnormal smears has had a smear showing borderline changes. A repeat smear after 6 months is normal. A repeat smear after 3 years shows inflammatory changes. A repeat smear after 6 months is normal. A repeat smear after 3 years shows borderline changes. What management will you suggest?

Scenario 11

A woman with no previous abnormal smears has had a smear showing mild dyskaryosis of squamous cells. What management will you suggest?

Scenario 12

A woman with no previous abnormal smears has had a smear showing moderate dyskaryosis of squamous cells. What management will you suggest?

Scenario 13

A woman with no previous abnormal smears has had a smear showing severe dyskaryosis of squamous cells. What management will you suggest?

Scenario 14

A woman with no previous abnormal smears has had a smear suggestive invasive disease. What management will you suggest?

Scenario 15

A woman with no previous abnormal smears has had a smear showing borderline nuclear changes in glandular cells. What management will you suggest?

Scenario 16

A woman with no previous abnormal smears has had a smear showing ?glandular neoplasia. What management will you suggest?

Scenario 17.

A woman with no previous abnormal smears has had a smear showing normal endometrial cells. What management will you suggest?

Scenario 18.

A woman with no previous abnormal smears has had a smear showing atypical endometrial cells. What management will you suggest?

Scenario 19

A woman with no previous abnormal smears has had a smear with a normal result. Clinical examination was normal, but contact bleeding was noted when the smear was taken. What management will you suggest?

Scenario 20

An American woman with no previous abnormal smears has been used to having annual smears. She has had a smear with a normal result and requests a repeat in 12 months. What management will you suggest?

Scenario 21

A woman with no previous abnormal smears is on renal dialysis and has had a smear with a normal result. What management will you suggest?

Scenario 22

A HIV +ve woman with no previous abnormal smears has had a smear with a normal result. What management will you suggest?

Scenario 23

A woman with no previous abnormal smears has had a smear with a normal result. She smokes 20 cigarettes daily and has a long history of recurrent genital warts. What management will you suggest?

Scenario 24.

A woman of 70 presents with postmenopausal bleeding. She had smears at the recommended intervals from the age of 22. All were normal. The last was taken at the age of 64. What is your management in relation to taking a smear?

Scenario 25.

A woman of 55 presents with hot flushes since her periods stopped at the age of 54. She wishes to go on HRT and there are no contraindications. She had smears at the recommended intervals from the age of 25. All were normal. The last was taken two years ago. What is your management in relation to taking a smear?

Scenario 26.

Women who have been treated for CIN are 2 – 5 times more likely to develop cancer than women who have not been treated. True or false?

Scenario 27.

More than 50% of women who develop cervical cancer have been lost to follow-up. True or false?

Scenario 28.

Which of the following statements are true and which false?

a.  cone biopsy is linked to ↓risk of recurrence compared to LLETZ.

b.  excision margins that are not CIN-free ↑ the risk of recurrence, with endocervical margins that are not CIN-free posing a greater risk that similar ectocervical margins.

c.   age > 35 years increases the risk of recurrent disease.

d.  follow-up after treatment for CIN should start between 3 & 6 months from the time of treatment.

e.  the initial examination should be with colposcopy plus cytology.

f.   a failure to achieve negative results in the year after treatment means colposcopy should be done.

g.  a required standard for treatment success is that ≥ 90% of women should have no evidence of dyskaryosis in the year after treatment.

h.  a required standard for treatment success is that there should be ≤ 5% of histologically-confirmed treatment failures by 1 year after treatment.

Scenario 29

Women who have had normal follow-up results for 2 years after treatment of CIN 1 can revert to the routine recall.

Scenario 30.

Follow-up should continue with increased frequency for 5 years after treatment of CIN 2 & 3, after which recall at routine intervals is OK if all the follow-up has been normal. True or false?

Scenario 31.

A woman with LLETZ for CIN3 twelve months ago had a normal smear 6 months later. A smear taken 12 months after treatment is also normal. What management will you suggest?

Scenario 32.

A woman with LLETZ for CIN3 twelve months ago had a normal smear 6 months later. A smear taken 12 months after treatment shows mild dyskaryosis. What management will you suggest?

Scenario 33.

A woman on normal recall has hysterectomy for menorrhagia. There is no evidence of CIN on histology. What follow-up would you recommend?

Scenario 34.

A woman who was not on normal recall has hysterectomy for menorrhagia. There is no evidence of CIN on histology. What follow-up would you recommend?

Scenario 35.

Women who have had hysterectomy and require follow-up with vault smears cannot be managed within the NHSCSP. True or False?

Scenario 36.

A woman who was not on normal recall has hysterectomy for menorrhagia. There is evidence of completely excised CIN3 on histology. What follow-up would you recommend?

Scenario 37.

A woman who was not on normal recall has hysterectomy for menorrhagia. There is evidence of incompletely excised CIN3 on histology. What follow-up would you recommend?

Scenario 38.

A woman has conservative treatment for early stage cancer of the cervix. What follow-up should be recommended?

Scenario 39.

A woman is referred with severe dyskaryosis, but colposcopy is normal. What follow-up should be recommended?

32. Cowden syndrome.

Scenario 1.

Lead in.

Which feature is associated with Cowden syndrome?

Option list.

A.     albinism

B.     hamartoma

C.     hammer-toe

D.     hypertrichosis

E.     stammer

Scenario 2.

Lead in. Which condition has the highest risk of occurrence in women with Cs?

Option list.

A.     breast cancer

B.     bowel cancer

C.     congenital absence of Müllerian tract derivatives

D.     hypertension

E.     hypothyroidism

Scenario 3.

Lead in. Which gynaecological cancer is a particular risk for women with Cs?

Option list.

A.     Bartholin’s gland cancer

B.     cervical cancer

C.     choriocarcinoma

D.     endometrial cancer

E.     vulval cancer

Scenario 4.

Lead in. Which cancer has increased risk for men with Cs?

Option list.

A.     breast cancer

B.     colon cancer

C.     melanoma

D.     renal cancer

E.     thyroid cancer

F.      all of the above

33. PALB2 mutations.

Lead-in.

The following scenarios relate to PALB2 mutations

Pick one option from the option list.

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

Scenario 1.  What does the acronym PALB2 mean?

Option list.        

         A.  Partner and localiser of BRCA2

         B.  Partial amyl-lipase bearer

         C. Pulmonary and liver beta-hydrogenase 2

         D.  Patently absurd language bashing

         E.  My second-best friend in secondary school

Scenario 2.  What kind of gene is PALB2?

Option list.

         A.  cytochrome P450 inducing gene

B.  DNA repair gene

         C.  RNA repair gene

         D.  maternal mitochondrial gene

Scenario 3.  Which female cancer is particularly linked to loss-of-function mutations in PALB2?

Option list.

         A.  breast cancer

         B.  cervical cancer

         C.  choriocarcinoma

         D.  endometrial cancer

         E.  ovarian cancer.