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EMQ. Obstetric cholestasis 1
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EMQ. Obstetric cholestasis 2
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EMQ. Diabetes & pregnancy
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EMQ. Down syndrome screening.
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EMQ. BRCA1 & 2.
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Viva. CNST.
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42. Obstetric cholestasis. (OC). 1.
Lead-in.
The following scenarios relate to the definition and diagnosis.
Pick one option from the option list.
Each option can be used once, more than once or not at
all.
Abbreviations.
gamma GT: gamma-glutamyl transferase
Option list.
A.
true
B.
false
C.
don’t be daft
D.
pruritus of pregnancy
with no other explanation which is associated with abnormal LFTs, raised bile
acids and pale stools, all of which resolve postnatally
E.
pruritus of pregnancy
with no other explanation which is associated with abnormal LFTs, ± raised bile
acids and pale stools, all of which resolve postnatally
F.
pruritus of pregnancy
with no other explanation which is associated with abnormal LFTs, ± raised bile
acids, all of which resolve postnatally
G.
pruritus of pregnancy with no other explanation
which is associated with abnormal LFTs (using pregnancy-specific ranges), ±
raised bile acids and pale stools, all of which resolve postnatally
H.
pruritus of pregnancy
with no other explanation which is associated with abnormal LFTs (using pregnancy-specific
ranges), ± raised bile acids, all of which resolve postnatally
I.
levels do not usually
rise in pregnancy
J.
mostly originates in
the placenta
K.
levels vary with the
time of day
L.
no information in the
GTG
M.
none of the above
Scenario 1.
The international definition of OC was agreed at a
conference in Tokyo in 1985.
Scenario 2.
What is the GTG’s definition of OC?
Scenario 3.
What is the incidence of pruritus in pregnancy?
Scenario 4.
Hepatitis B and C, but not
hepatitis A, may cause pruritus and abnormal LFTs in pregnancy.
Scenario 5.
Infection with the Ebstein Barr
virus may cause pruritus and abnormal LFTs in pregnancy.
Scenario 6.
The cytomegalovirus may cause
pruritus and abnormal LFTs in pregnancy.
Scenario 7.
The herpes zoster virus may
cause pruritus and abnormal LFTs in pregnancy.
Scenario 8.
Chronic active hepatitis and
secondary biliary cirrhosis are included in the GTG’s list of conditions to be
considered in the differential diagnosis.
Scenario 9.
Bilirubin levels are normally
elevated in the early stages of OC and remain elevated until the condition
resolves after delivery.
Scenario 10.
Liver function tests become abnormal as soon as the
pruritus is noted.
Scenario 11.
Levels of bile acids commonly rise significantly after
meals making fasting levels mandatory for diagnosis.
Scenario 12.
The upper limit of normal for transaminases, gamma GT and
bile acids is about 20% lower in pregnancy.
Scenario 13.
Once a diagnosis of OC has been
made, tests of liver function should not be repeated until the puerperium
Scenario 14.
LFTs should be checked weekly
until they have returned to normal after delivery of the baby in a case of OC.
Scenario 15.
Once a diagnosis of OC has been
made, the activated partial thromboplastin time (APTT) should be measured and a
full coagulation screen done if it is prolonged.
Scenario 16.
Delivery at 37 weeks should be
recommended because of the risk of FDIU in the later weeks of pregnancy.
Scenario 17.
What additional pre-labour
monitoring of fetal welfare is advisable in the third trimester?
Scenario 18.
Prophylactic steroids should be
offered at 28 weeks because of the risk of spontaneous premature labour.
43. Obstetric cholestasis. (OC). 2.
Lead-in.
The following scenarios relate to the prevalence of OC.
Pick one option from the option list.
Each option can be used once, more than once or not at
all.
Option list.
A.
0.1%
B.
0.5%
C.
0.7%
D.
1 – 1.2%
E.
1.2% to 1.5%
F.
1.5 – 2%
G.
2.4%
H.
3 – 3.5%
I.
5%
J.
7%
K.
15%
L.
white
M. brown
N.
blue-green
O.
red-brown, striped
P.
no information in the
GTG
Q.
none of the above
Scenario 1.
What is the overall prevalence
in the UK population?
Scenario 2.
What is the overall prevalence
in the Indian and Pakistani Asian populations?
Scenario 3.
What is the overall prevalence
in Scandinavia?
Scenario 4.
What is the overall prevalence in Chile?
Scenario 5.
What is the overall prevalence in Araucanian Indians?
Scenario 6.
What is the overall prevalence
in Eskimos?
Scenario 7.
What is the incidence of pruritus in pregnancy?
Scenario 8.
What colour of eggs do
Araucanian chickens lay?
44. 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
Z.
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.
45. Screening for Down’s syndrome.
Lead-in.
The following scenarios relate to screening for Down’s
syndrome.
Pick one option from the option list.
Each option can be used once, more than once or not at
all.
Abbreviations.
DS. Down’s syndrome.
FASC: Fetal Anomaly Screening Programme.
NSC: National Screening Committee
Suggested reading.
Option list.
a. 1 in 2
b. 1 in 5
c. 1 in 10
d. 1 in 20
e. 1 in 40
f.
1 in 250
g. 1 in 400
h. 1 in 1,000
i.
5 mm.
j.
6 mm.
k. 7 mm.
l.
8 mm.
m. 10 mm.
n. 1%
o. 2%
p. 5%
q. 10%
r.
80%
s. 95%
t.
90%
u. 95%
v. higher
w. lower
x. true
y. false
z. none of the above.
Scenario 1.
What is the age-related risk of
DS at 20 years?
Scenario 2.
What is the age-related risk of
DS at 30 years?
Scenario 3.
What is the age-related risk of
DS at 35 years?
Scenario 4.
What is the age-related risk of
DS at 40 years?
Scenario 5.
What is the age-related risk of
DS at 45 years?
Scenario 6.
AFP levels are lower in Ds.
Scenario 7
Inhibin levels are raised in
DS.
Scenario 8
Oestriol levels are raised in
DS.
Scenario 9
β-hCG levels are raised in DS.
Scenario 10
1st. trimester PAPP-A levels are lower in DS.
Scenario 11
2nd. trimester PAPP-A levels are normal in DS.
Scenario 12
What
characteristic is described in relation to the occipital hairline in DS?
Scenario 13
What
characteristic is described in relation to the frontal hairline in DS?
Scenario 14
What is the
incidence of congenital heart anomaly in DS?
Scenario 15
Which is the most
common congenital heart anomaly in DS?
Scenario 16
Which major
haematological condition is more common in those with DS?
Answer.
Scenario 17
Which major
neurological condition is more common in middle
age in those with DS?
Scenario 18
Which spinal
anomaly is more common in DS and of concern to anaesthetists?
46. BRCA1 & 2 carriers and risk of breast and ovarian
cancer.
There is no option list – you have to produce your own
numbers.
Scenario 1.
A woman of 30 has two sisters who developed breast cancer
before the age of 40. They and she have been proved to be carriers of BRCA1.
She attends the gynaecology clinic requesting information
about her lifetime risk of breast cancer.
What is the approximate figure?
Scenario 2.
A woman of 30 has two sisters who developed breast cancer
before the age of 40. They and she have been proved to be carriers of BRCA1.
She attends the gynaecology clinic requesting information
about her lifetime risk of ovarian cancer.
What is the approximate figure?
Scenario 3.
A woman of 30 has two sisters who developed breast cancer
before the age of 40. They and she have been proved to be carriers of BRCA2.
She attends the gynaecology clinic requesting information
about her lifetime risk of breast cancer.
What is the approximate figure?
Scenario 4.
A woman of 30 has two sisters who developed breast cancer
before the age of 40. They and she have been proved to be carriers of BRCA2.
She attends the gynaecology clinic requesting information
about her lifetime risk of ovarian cancer.
What is the approximate figure?
Scenario 5
The woman asks for the overall figure for lifetime risk
of breast cancer in UK women for comparison with her risk.
What is the approximate figure?
Scenario 6
The woman asks for the overall UK figure for lifetime
risk of ovarian cancer for comparison with her risk.
What is the approximate figure?
Scenario 7
Which of
the following genes have mutations that increase the risk of female breast
cancer?
Answer.
A
|
ATM
|
B
|
CDH1
|
C
|
CHEK1
|
D
|
FATHEAD
|
E
|
MARBELLA
|
F
|
NBENE
|
G
|
p45
|
H
|
p53.
|
I
|
PALB2
|
J
|
PNINE
|
K
|
PTEN
|
L
|
RADON50
|
M
|
RINT1
|
Scenario 8
A man of 30 has two sisters who developed breast cancer before
the age of 40. They and he have been proved to be carriers of BRCA2.
His GP phones to ask about his lifetime risk of breast cancer.
What is the approximate figure?
Scenario 9
A man of 30 has two sisters who developed breast cancer before
the age of 40. They and he have been proved to be carriers of BRCA2.
His GP phones to ask about his lifetime risk of ovarian cancer.
What is the approximate figure?
Scenario 10
A woman of 30 has two sisters who developed breast cancer
before the age of 40. They and she have been proved to be carriers of BRCA2.
She attends the gynaecology clinic requesting information
about the value of prophylactic mastectomy. What advice will you give about
efficacy?
Scenario 11
A woman of 30 has two sisters who developed breast cancer
before the age of 40. They and she have been proved to be carriers of BRCA2.
She attends the gynaecology clinic requesting information
about the benefits of prophylactic salpingo-oophorectomy – her family is
complete and her husband has had vasectomy. What is the approximate figure for
the efficacy of salpingo-oophorectomy in relation to cancer?
Scenario 12
A woman of 30 has two sisters who developed breast cancer
before the age of 40. They and she have been proved to be carriers of BRCA1.
She attends the gynaecology clinic requesting information
about the benefits of prophylactic salpingo-oophorectomy. What are the
disadvantages of BSO?
Scenario 13
A woman of 30 has two sisters who developed breast cancer
before the age of 40. They and she have been proved to be carriers of BRCA1.
She attends the gynaecology clinic requesting information
about the benefits of prophylactic salpingo-oophorectomy. What alternatives should be discussed?
Scenario 14
A woman of 30 has two sisters who developed breast cancer
before the age of 40. They and she have been proved to be carriers of BRCA1.
Which drugs are of proven value in reducing breast cancer
risk for women like her?
Scenario 15
A woman of 30 has two sisters who developed breast cancer
before the age of 40. They and she have been proved to be carriers of BRCA2.
Which drugs are of proven value in reducing breast cancer
risk for women like her?
Scenario 16
A woman of 30 has two sisters who developed breast cancer
before the age of 40. They and she have been proved to be carriers of BRCA1.
Which drugs are of proven value in reducing ovarian
cancer risk for women like her?
Scenario 17
A woman of 30 has two sisters who developed breast cancer
before the age of 40. They and she have been proved to be carriers of BRCA2.
Which drugs are of proven value in reducing ovarian
cancer risk for women like her?
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