Monday, 2 February 2015

Tutorial 2 February 2015


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2 February 2015.

42.    
SBA. NICE Clinical Guideline 132. Caesarean section.
43.    
SBA. Pertussis
44.    
SBA. Kisspeptin
45.    
EMQ. Hepatitis B.
46.    
Viva. CNST.


1 Caesarean section. NICE Clinical Guideline 132.
Lead-in.
The following scenarios relate to Caesarean section.
Abbreviations.
cART:                           combination anti-retroviral treatment.
CDUS:                          colour Doppler ultrasound scan.
HAART:                       highly active anti-retroviral therapy.
HCV:                            hepatitis C virus.
HSV:                            herpes simplex virus.
MOD:                          mode of delivery.
MPA:                           morbid placental adherence.
MRI:                            magnetic resonance imaging.
MTCT:                         mother-to-child transmission.
NVD:                           normal vaginal delivery.
pCs                              planned Caesarean section.
pvd                              planned vaginal delivery.
PVL:                             plasma viral load.
SROM:                        spontaneous rupture of membranes.
VBAC:                          vaginal birth after Caesarean section.

Option list.
There is none, to make you think!
Scenarios.
1)      MPA is suspected on a routine 20 week scan in a woman who has had two LSCSs. What advice should she be given in relation to the value of colour Doppler US and MRI? 
2)      What advice is given about women who are infected with hepatitis B?
a      a woman is known to have HIV. When should a decision be taken about MOD?
b.     at what gestation should pCs be done as part of management of HIV in pregnancy?
c.      at what gestation should pCs be done in the woman with HIV, if the grounds are obstetric or the woman’s wish, but not part of the management of HIV?
d.     what advice about MOD should be given to a woman with PVL <50 HIV RNA copies/mL at 36 weeks?
e.     what advice about MOD should be given to a woman with PVL of 200 HIV RNA copies/mL at 36 weeks?
f.      what advice about MOD should be given to a woman with PVL of 300 HIV RNA copies/mL at 36 weeks?
g.     what advice about MOD should be given to a woman with PVL of 400 HIV RNA copies/mL at 36 weeks?
h.     what advice about MOD should be given to a woman with PVL of 600 HIV RNA copies/mL at 36 weeks?
i.      a woman with HIV has been advised that normal delivery is recommended. What additional interventions should be offered when she goes into labour?
k.     what is an elite controller?
        
1
member of the staff of Black Rod in the House of Lords
2
crowd marshal at the Members’ Pavilion at Lord’s Cricket Ground.
3
Gentleman Usher at Buckingham Palace party
4
one of the anti-retroviral drugs that are essential components of HAART.
5
individual who is infected with HIV but maintains low viral and healthy CD4 counts long-term with ART.
6
individual who is infected with HIV but maintains low viral and healthy CD4 counts long-term without ART.

l.      a woman is taking zidovudine monotherapy. Her PVL is <50 HIV RNA copies/mL at 36 weeks? What advice would you give re MOD?
m.    a woman is taking zidovudine monotherapy. Her PVL is 200 HIV RNA copies/mL at 36 weeks? What advice would you give re MOD?
n.     a woman is taking zidovudine monotherapy. Her PVL is 500 HIV RNA copies/mL at 36 weeks? What advice would you give re MOD?
o.     a woman is an elite controller. What advice will you give re MOD?

3)      What advice is given about women who are infected with hepatitis C
4)      What advice is given about women who are infected with HIV?
5)      What advice is given about women who are infected with HIV + hepatitis B?
6)      What advice is given about women who are infected with HIV + hepatitis C
7)      A woman with HIV takes HAART and has a PVL < 50 copies per ml. She wishes Caesarean section for non-obstetric reasons. She has been counselled and Caesarean section has been agreed. At what gestation should it be done?
8)      What advice should be given to the woman with HSV infection in pregnancy?
9)      What is the risk of MTCT after primary HSV infection in the 3rd. trimester?
10)   A woman presents with genital herpes at 36 weeks’ gestation in her first pregnancy. As far as she is aware, this is her first episode of HSV infection. What is the chance that it is a recurrent infection?
11)   A woman presents with genital herpes at 36 weeks’ gestation in her third pregnancy. As far as she is aware, this is her first episode of HSV infection. What is the chance that it is a recurrent infection?
12)   A woman presents with genital herpes at 36 weeks’ gestation in her first pregnancy. As far as she is aware, this is her first episode of HSV infection. What test should be done to clarify whether it is a 1ry. or recurrent infection?
13)   A woman presents with genital herpes at 36 weeks’ gestation in her first pregnancy. As far as she is aware, this is her first episode of HSV infection. Swabs are taken from the skin lesions and blood is taken for HSV type-specific antibodies. She goes into labour at 38 weeks before the results of the HSV type specific antibody tests are available. What advice should be given re mode of delivery?
14)   A woman presents with genital herpes at 36 weeks’ gestation in her first pregnancy. As far as she is aware, this is her first episode of HSV infection. Swabs are taken from the skin lesions and blood is taken for HSV type-specific antibodies and confirm 1ry.  infection.  She goes into labour with intact membranes at 38 weeks and declines Cs. What action should be taken with regard to anti-viral treatment?
15)   A woman presents in labour at 38 week’s gestation, 2 weeks after a 1ry. infection with genital HSV. She declines Caesarean section, but opts for antiviral treatment for her and the baby. Which drug should be considered and in what doses?
16)   A woman presents in labour at 38 week’s gestation, 2 weeks after a 1ry. infection with genital HSV. She had SROM 6 hours before.
17)   A woman presents in early labour at 38 weeks’ gestation. She has a history or recurrent genital HSV. She has a typical herpetic blister on the vulva. What risk of neonatal infection will you quote in the discussion?
18)   A woman presents in labour at term with lesions and a history that are typical of 1ry. genital HSV infection. Which invasive procedures, if any, should be avoided?
19)   A woman with a history of recurrent genital herpes presents in labour at 40 weeks with a typical vulval herpetic blister. Which invasive procedure, if any, should be avoided?
20)   A baby is born by Caesarean section after maternal 1ry. genital herpes one month before. Which, if any, of the following are appropriate?
Option list.
A.      liaise with the neonatal unit
B.      normal postnatal care of the baby with examination at 24 hours, then discharge if well and feeding is established.
C.      swabs of skin, conjunctiva, oropharynx and rectum for HSV PCR
D.      lumbar puncture for evidence of HSV
E.       parents to be educated re good hand hygiene
F.       i.v. acyclovir, 20 mg/kg 8 hourly until active infection is ruled out.
G.      strict infection control procedures should be put in place for both mother and baby.
H.      breastfeeding should be discouraged because of the presence of HSV in breast milk.
I.        parents advised to seek medical help if they have concerns, in particular, skin, eye or mucous membrane lesions, lethargy, irritability or poor feeding
21)   A baby is born normally after maternal 1ry. genital herpes one month before. The mother had declined C section and intends to breast feed. Which, if any, of the following are appropriate? Option list.
J.        liaise with the neonatal unit
K.       normal postnatal care of the baby with examination at 24 hours, then discharge if well and feeding is established.
L.       swabs of skin, conjunctiva, oropharynx and rectum for HSV PCR
M.    lumbar puncture for evidence of HSV
N.      parents to be educated re good hand hygiene
O.     i.v. acyclovir, 20 mg/kg 8 hourly until active infection is ruled out.
P.       strict infection control procedures should be put in place for both mother and baby.
Q.     breastfeeding should be discouraged because of the presence of HSV in breast milk.
R.      parents advised to seek medical help if they have concerns, in particular, skin, eye or mucous membrane lesions, lethargy, irritability or poor feeding,
S.       involvement of child protection service.
22)   A baby is born by Caesarean section after maternal 1ry. genital herpes one month before. Which, if any, of the following are appropriate?
Option list.
T.       liaise with the neonatal unit
U.      normal postnatal care of the baby with examination at 24 hours, then discharge if well and feeding is established.
V.      swabs of skin, conjunctiva, oropharynx and rectum for HSV PCR
W.    lumbar puncture for evidence of HSV
X.       parents to be educated re good hand hygiene
Y.       i.v. acyclovir, 20 mg/kg 8 hourly until active infection is ruled out.
Z.       strict infection control procedures should be put in place for both mother and baby.
AA.  breastfeeding should be discouraged because of the presence of HSV in breast milk.
BB.  parents advised to seek medical help if they have concerns, in particular, skin, eye or mucous membrane lesions, lethargy, irritability or poor feeding
23)   What proportion of neonatal HSV infection is thought to be due to infection after birth?
24)   What steps should be taken to reduce the risk of neonatal HSV infection?
25)   A primigravida attends for booking. She requests Caesarean section. There are no clinical grounds. Outline your management.   
26)   A woman with BMI > 50 should be offered Caesarean section. True/ False.
27)   When should prophylactic antibiotics in relation to the timing of the operation?
28)   A woman has had her 3rd. Caesarean section. She wants to know the advice you would give re the risks of subsequent vaginal delivery.
29)   What are the key aspects of induction of general anaesthesia for unplanned Cs?
30)   What should be done about thromboprophylaxis for women having Cs?
31)   Which abdominal incision is recommended for Cs?
A
William Fletcher Shaw
B
Victor Bonney
C
Ignaz Semmelweis
D
Joel-Cohen
E
Pfannenstiel
32)   Separate scalpels should be used for the skin and subsequent incisions to reduce infection. True/False.
33)   If the lower segment is well-formed, blunt dissection should be used to extend the initial uterine incision. True / False.
34)   What is the risk of fetal laceration?
A
0.1%
B
0.5%
C
1%
D
2%
E
5%
35)   Routine use of forceps to deliver the head is acceptable practice. True / False.
36)   I.v. syntometrine is the recommended oxytocic. True / False.
37)   Which of the following statements reflects the advice in CG132 about delivery of the placenta.
A
Crede’s manoeuvre is the recommended routine method for DOP
B
Leopold’s  manoeuvre is the recommended routine method for DOP
C
Steptoe’s manoeuvre is the recommended routine method for DOP
D
CCT is the recommended routine method for DOP
E
MROP manoeuvre is the recommended routine method for DOP
38)   Co-amoxiclav is on the list of recommended antibiotics in CG132 for routine prophylaxis at Cs. True / False.
39)   Repair of the uterus is best done with the uterus exteriorised. True / False.
40)   CG132 advises that single or double-layer closure of the lower segment are equivalent and closure is a matter of choice for the surgeon. True / False.
41)   CG132 advises closure of both visceral and parietal peritoneum. True / False.
42)   Mass closure with a non-absorbable suture should be used for closure of mid-line incisions. True / False.
43)   What is the suggested threshold for closure of the subcutaneous fat?

Subcutaneous fat thickness
A
1 cm.
B
2 cm.
C
3 cm.
D
4 cm.
E
≥ 5 cm.
44)   Liberal use of subcutaneous drains is encouraged to reduce wound infection rates. True / False.
45)   When choosing an antibiotic for prophylactic use at Cs, what infections should particularly be considered?
46)   Staff should be silent immediately before and after the birth of the baby as hearing the mother’s voice as the first ex-utero experience encourages bonding. True / False.

2. Pertussis.
Question 1.
Lead-in. Why is pertussis of current concern in obstetrics?
Option List
A.       
Recent research has linked pertussis in the 1st. trimester with an ↑risk of congenital heart disease
B.       
There has been a mini-epidemic of pertussis since 2011 with an increase in maternal deaths and deaths of babies < 3 months
C.       
There has been a mini-epidemic of pertussis since 2011 with an increase in deaths of babies < 3 months
D.       
The infecting organism causing pertussis has become increasingly drug-resistant
E.        
Pertussis in the 2nd. trimester doubles the risk of premature delivery < 32 weeks

Question 2.
Lead-in
Which of the following statements is true?
Option List
A.       
Pertussis is not a notifiable disease
B.       
Pertussis is a notifiable disease
C.       
Pertussis is not a notifiable disease, but cases should be reported to the local bacteriologist
D.       
Pertussis is not a notifiable disease, but cases should be subject to audit

Question 3.
Lead-in
Which organism causes whooping cough?
Option List
A.       
Bordella pertussis
B.       
Bacteroides pertussis
C.       
Rotavirus whoopoe
D.       
Respiratory syncytiovirus pertussis
E.        
None of the above

Question 4.
Lead-in
What is the main reservoir of the organism that causes pertussis?
Option List
A.       
pigs
B.       
pigeons
C.       
budgerigars
D.       
humans
E.        
none of the above

Question 5.
Lead-in
What is the epidemiology of pertussis?
Option List
A.       
the condition is endemic
B.       
the condition is endemic with mini-epidemics every 3-5 years
C.       
the condition is endemic with mini-epidemics most years in the winter months
D.       
the condition is epidemic, with outbreaks at roughly three-year intervals
E.        
the condition is epidemic, with outbreaks at unpredictable intervals

Question 6.
Lead-in
What practical issues are current for obstetrician in relation to pertussis?
Option List

A.       
The DOH has advised that all pregnant women be immunised to reduce maternal death rates.
B.       
The DOH has advised that all pregnant women be immunised to reduce deaths in babies < 3 months.
C.       
The DOH has advised that all babies be immunised at birth.
D.       
The DOH has advised that “Boostrix- IPV would replace “Repevax” for use in pregnancy from July 2014.
E.        
The DOH has advised that immunisation of pregnant women be continued until 2019

Question 7.
Lead-in
Which, if any, of the following statements are true in relation to pertussis vaccine.
Option List

A.       
Boostrix- IPV” is a vaccine for pertussis only
B.       
“Repevax” is a vaccine for pertussis only
C.       
Boostrix- IPV”& “Repevax” are live, attenuated vaccines
D.       
Boostrix- IPV” & “Repevax” are vaccines against diphtheria, tetanus and polio as well as pertussis
E.        
Boostrix- IPV”  & “Repevax” are acellular


3. Kisspeptin.

In relation to kisspeptin, pick the best answer from the list below.
A.       
is a pheromone released by the hypothalamus during passionate embraces
B.       
is a digestive enzyme released by the salivary glands during passionate embraces
C.       
is a digestive enzyme found in human carnivores but not vegetarians
D.       
does not exist
E.        
is thought necessary for trophoblastic invasion and low levels have been linked to miscarriage and recurrent miscarriage

4. Hepatitis B and pregnancy.
Lead-in.
Each of the following scenarios relates to hepatitis B and pregnancy.
Instructions.
For each scenario, select the most appropriate option from the option list.
Each option can be used once, more than once or not at all.
Abbreviations.
HBcAg:      hepatitis B core antigen
HBeAg:      hepatitis B e antigen           
HBsAg:      hepatitis B surface antigen
HBcAb:      antibody to hepatitis B core antigen
HBeAb:     antibody to hepatitis B e antigen
HBsAb:      antibody to hepatitis B surface antigen
HBIG:         hepatitis B immunoglobulin
HBV:          hepatitis B virus
Option list.
A.      acyclovir
B.      divorce
C.      HBcAg +ve
D.     HBeAg +ve
E.      HbsAg +ve
F.       HBsAg +ve; HBsAb –ve; HBcAb -ve
G.     HBsAg +ve; HBsAb –ve on two tests six months apart
H.     HBsAG –ve; HBsAb -ve on two tests six months apart
I.        HBsAg –ve; HBsAb +ve; HBcAb –ve
J.        HBsAg –ve; HBsAb +ve; HBcAb +ve
K.      HBsAg –ve; HBsAb +ve
L.       HBsAg +ve; HBcAg +ve
M.   HBV vaccine.
N.     HBIG
O.     HBV vaccine + HBIG
P.      immune as a result of infection
Q.     immune as a result of vaccination
R.      not immune
S.       chronic carrier of HBV infection
T.      10%
U.     30%
V.      50%
W.   60%
X.      70 - 90%
Y.      soap and boiling water
Z.       10% dilution of bleach in water
AA. 10% dilution of formaldehyde in alcohol
BB.  ultraviolet irradiation
CC.  yes
DD.no
EE.  none of the above

Scenario 1.
An asymptomatic primigravida books at 10 weeks. Her partner had an acute HBV infection 4 months ago. What results on routine blood testing would indicate that she has an acute infection?
Scenario 2.
An asymptomatic primigravida books at 10 weeks. Her partner had an acute HBV infection 4 months ago. What results on routine blood testing would indicate that she is immune to the HBV as a result of natural infection?
Scenario 3.
An asymptomatic primigravida books at 10 weeks. Her partner had an acute HBV infection 4 months ago. What results on routine blood testing would indicate that she is immune to the HBV as a result of HBV vaccine?
Scenario 4.
An asymptomatic primigravida books at 10 weeks. Her partner had an acute HBV infection 6 months ago. What results on routine blood testing would indicate that she is a chronic carrier of HBV infection?
Scenario 5.
Testing shows that he is positive for HBsAg, positive for HBcAb but negative for IgM HBcAb. What does this mean in relation to his HBV status?
Scenario 6.
Testing shows that he is negative for HBsAg, positive for HBcAb and positive for HBsAb.
What does this mean in relation to his HBV status?
Scenario 7
A primigravid woman at 8 weeks gestation is found to be non-immune to the HBV. She has recently married and her husband is a chronic carrier. What should be done to protect her from infection?
Scenario 8
A woman is a known carrier of Hepatitis B. What is the risk of vertical transmission in the first trimester?
Scenario 9
A woman is a known carrier of Hepatitis B. What is the risk of the neonate who has been infected by vertical transmission in the third trimester becoming a carrier without treatment?
Scenario 10
How effective is hepatitis B prophylaxis in preventing chronic carrier status developing in a neonate infected as a result of vertical transmission?
Scenario 11
Can a woman who is a chronic HBV carrier breastfeed safely?
Scenario 12.
Hepatitis B infection is the most dangerous of the viral hepatitis infections in pregnancy.
Scenario 13.
A pregnant woman who is not immune to HBV has a partner who is a chronic carrier. Can HBV vaccine be administered safely in pregnancy?
Scenario 14.
A pregnant woman who is not immune has a partner with acute hepatitis due to HBV. He cuts his hand and bleeds onto the kitchen table. How should she clean the surface to ensure that she gets rid of the virus?
Scenario 15.
Is it true that the presence of HBeAg in maternal blood is a particular risk factor for vertical transmission? Not really a scenario, but never mind! Yes / No.

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