Thursday 3 December 2015

Tutorial 3rd. December 2015


15
SBA. The PROMISE trial
16
EMQ. The coroner
17
EMQ. Early pregnancy. Diagnoses to exclude
18
EMQ. Early pregnancy. Management.
19
Communication skills.

15.        PROMISE trial.
Question 1.
Lead-in
What does the acronym “PROMISE” mean?
Option List
A.       
Per-Rectal Oestrogen and recurrent MIScarriage Evaluation
B.       
PROgrammed cognitive behaviour therapy and MIScarriage Evaluation
C.       
PROgesterone and recurrent MIScarriage
D.       
PROgesterone in early MIScarriage
E.        
PROfessional MISinformation and satisfaction levels in women with recurrent miscarriage

Question 2.
Lead-in
What is the risk of miscarriage in proven pregnancy for girls aged 12-19?
Option List
A.       
>10 - ≤15%
B.       
>15 - ≤25%
C.       
>25 - ≤50%
D.       
>50 - ≤90%
E.        
>90%

Question 3.
Lead-in
What is the risk of miscarriage in proven pregnancy for women aged 20- 29?
Option List
A.       
>10 - ≤15%
B.       
>15 - ≤25%
C.       
>25 - ≤50%
D.       
>50 - ≤90%
E.        
>90%

Question 4.
Lead-in
What is the risk of miscarriage in proven pregnancy for women aged 30 – 34?
Option List
A.       
>10 - ≤15%
B.       
>15 - ≤25%
C.       
>25 - ≤50%
D.       
>50 - ≤90%
E.        
>90%

Question 5.
Lead-in
What is the risk of miscarriage in proven pregnancy for women aged 35-39?
Option List
A.       
>10 - ≤15%
B.       
>15 - ≤25%
C.       
>25 - ≤50%
D.       
>50 - ≤90%
E.        
>90%

Question 6.
Lead-in
What is the risk of miscarriage in proven pregnancy for women aged 40 – 44?
Option List
A.       
>10 - ≤15%
B.       
>15 - ≤25%
C.       
>25 - ≤50%
D.       
>50 - ≤90%
E.        
>90%

Question 7.
Lead-in
What is the risk of miscarriage in proven pregnancy for women aged ≥45?
Option List
A.       
>10 - ≤15%
B.       
>15 - ≤25%
C.       
>25 - ≤50%
D.       
>50 - ≤90%
E.        
>90%

Question 8.
Lead-in
What is the definition of recurrent miscarriage?
Option List
A.       
Two or more miscarriages
B.       
Two or more miscarriages if no livebirths
C.       
Three or more miscarriages
D.       
Three or more miscarriages if no livebirths
E.        
None of the above.

Question 9.
Lead-in
What is the incidence of recurrent miscarriage?
Option List
A.       
0.1 %
B.       
0.5 %
C.       
1.0 %
D.       
2.0 %
E.        
5.0 %

Question 10.
Lead-in
What is the approximate chance of three consecutive miscarriages in the healthy population?
Option List
A.       
0.1%
B.       
0.5%
C.       
0.75%
D.       
1.0 %
E.        
2.0 %

Question 11.
Lead-in
What is the comparative incidence of genetically abnormal pregnancy in women with RM and those with sporadic miscarriage?
Option List
A.       
about the same
B.       
higher in women with RM
C.       
lower in women with RM
D.       
unknown for women with RM
E.        
it is beneath my dignity to answer such a simple question

Question 12.
Lead-in
What did the PROMISE trial compare?
Option List
A.       
risk of miscarriage in women with unexplained RM taking oral progestogerone
B.       
risk of miscarriage in women with unexplained RM taking vaginal micronized progesterone
C.       
chance of livebirth after 24 weeks in women with unexplained RM taking oral progestogerone
D.       
chance of livebirth after 24 weeks in women with unexplained RM taking vaginal micronized progesterone
E.        
chance of livebirth after 24 weeks in women with unexplained RM taking hCG supplementation + folic acid 5mg.

Question 13.
Lead-in
Approximately how many subjects were involved in the PROMISE trial?
Option List
A.       
600
B.       
800
C.       
1,000
D.       
2,000
E.        
5,000

Question 14.
Lead-in
Approximately what proportion of the women recruited to the PROMISE trial were lost to follow-up?
Option List
A.       
1%
B.       
5%
C.       
10%
D.       
15%
E.        
20%
F.        
the proportion is unknown

Question 15.
Lead-in
Approximately what proportion of women in the active arm of the PROMISE trial had a livebirth?
Option List
A
40%
B
50%
C
55%
D
60%
E
65%
F
70%

Question 16.
Lead-in
Approximately what proportion of women in the placebo arm of the PROMISE trial had a livebirth?
Option List
A
40%
B
50%
C
55%
D
60%
E
65%
F
70%

16.         The Coroner.
The Coroner. Question 1.
Lead-in.
The following scenarios relate to the role of the Coroner.
Pick one option from the option list.
Each option can be used once, more than once or not at all.
Option list.
A.        an independent judicial officer
B.         a barrister acting for the Local Police Authority
C.         the regional representative of the Home Office
D.        the regional representative of the Queen.
E.         an employee of the High Court.
F.         the Local Authority
G.        the Local Police Authority
H.        the Home Office
I.           the High Court
J.          the Queen

Scenario 1.
What is the best description of the status of the Coroner?
Scenario 2.
Who appoints the Coroner?
Scenario 3.
Who pays for the Coroner and the coronial service?

The Coroner. Question 2.
Lead-in.
The following scenarios relate to the role of the Coroner.
Pick one option from the option list.
Each option can be used once, more than once or not at all.
Option list.
A.        must have had experience as a detective in the police force with  rank of Inspector or above
B.         must be a barrister, lawyer or doctor with at least 5 years’ experience
C.         must be a legally qualified individual with at least 5 years’ experience
D.        must be a trained bereavement counsellor
E.         must be able to play the bagpipes
F.         Monday -  Friday; 09.00 - 17.00 hours, including bank holidays
G.        Monday - Friday; 09.00 - 17.00 hours, excluding bank holidays
H.        All the time
I.           to arrest people suspected of unlawful killing
J.          to manage traffic in the vicinity of the Coroner’s court
K.         to make enquiries on behalf of the Coroner
L.          to make enquiries on behalf of the Coroner and provide administrative support
M.      to play bagpipes at coronial funerals

Scenario 1.
What qualifications must the Coroner have?
Scenario 2.
What are the hours of availability of the Coroner?
Scenario 3.
What is the role of the Coroner’s Officers?

The Coroner. Question 3.
Lead-in.
The following scenarios relate to the role of the Coroner.
Pick one option from the option list.
Each option can be used once, more than once or not at all.
Option list.
A.        the death must be reported to the Coroner
B.         the death does not need to be reported to the Coroner
C.         the Coroner must order the return of the body for an inquest
D.        the Coroner must order a post-mortem examination
E.         the Coroner must hold an inquest
F.         the Coroner should arrange for the death to be investigated by the Home Office
G.        the death must be reported to the authorities of the country in which it took place in order that a certificate of death can be issued
H.        a certificate of live birth
I.           a certificate of stillbirth
J.          a certificate of miscarriage
K.         yes
L.          no
M.      none of the above
Scenario 1.
A resident of Manchester dies suddenly while visiting the town of his birth in Scotland. His family decides that he will be buried there. His body is held at the premises of a local funeral director. What actions should be taken with regard to the Manchester coroner?
Scenario 2.
A resident of London dies suddenly while visiting Manchester, where he was born. His family decides that he will be buried in Manchester. His body is held at the premises of a Manchester funeral director. What actions should be taken with regard to the Manchester coroner?
Scenario 3.
A resident of Manchester dies on holiday in his native Greece. The family decide that he will be buried in Greece. What steps must be taken to obtain a valid death certificate?
Scenario 4.
A man of 65 dies of terminal lung cancer. The GP visited daily until going on holiday three weeks before the death. He has now returned and says that he will sign a death certificate, but needs to visit the funeral director to see the body first.  Will this be a valid death certificate?
Scenario 5.
A man of 65 dies of terminal lung cancer. The GP, who visited daily up to the day of his death and attended to confirm the death, is on holiday. He says that he will sign a death certificate and put it in the post, so that it will arrive in the morning. Will this be a valid death certificate?
Scenario 6.
A man of 65 dies of terminal lung cancer. The GP, who visited daily up to the day before his death, has been on holiday since. However, he says that he will sign a death certificate and put it in the post, so that it will arrive in the morning. Will this be a valid death certificate?
Scenario 7.
A 65-year-old man dies suddenly 12 hours after admission to the local coronary care unit with chest pain, despite the apparently satisfactory insertion of a coronary artery stent after a diagnosis of coronary artery thrombosis. What action should be taken with regard to the Coroner?
Scenario 8.
A 16-year-old girl is admitted at 36 weeks’  gestation in her first pregnancy with placental abruption. She is given the best possible care but develops DIC and hypovolaemic shock and dies after 48 hours. What action should be taken with regard to the coroner?
Scenario 9.
A 28-year-old woman is admitted with placental abruption at 36 weeks. She has bruising on the abdominal wall and the admitting midwife suspects that she has been the victim of domestic violence, though the woman denies it. Despite best possible care she dies as a consequence of bleeding. What action should be taken with regard to the coroner?
Scenario 10.
A 30-year-old woman delivers normally at home attended by her husband, but has a PPH. The husband practises herbal medicine. He applies various potions but her condition deteriorates. She is admitted to hospital by emergency ambulance some hours later in a shocked condition. She is given the best possible care and is admitted to the ICU. She dies 7 days later of multi-organ failure and ARDS attributed to hypovolaemic shock. What action should be taken with regard to the coroner?
Scenario 11.
A woman is admitted at 23 weeks in premature labour. There is evidence of fetal heart activity throughout the labour, with the last record being 5 minutes before the baby delivers. The baby shows no evidence of life at birth. The mother requests a death certificate so that she can register the birth and arrange a funeral. What form of certificate should be issued?
Scenario 12.
A woman is admitted at 26 weeks’ gestation in premature labour. The presentation is footling breech. At 8 cm. cervical dilatation the trunk is delivered and the cord prolapses. There is good evidence of fetal life with fetal movements and pulsation of the cord. The head is trapped and it takes 5 minutes to deliver it. The baby is pulseless, apnoeic and without visible movement at birth. Intubation and CPR are carried out for 20 minutes when the baby is declared dead. What action should be taken with regard to the coroner?
Scenario 13.
A 65-year-old man dies 2 hours after admission to hospital with an apparent stroke. The coroner requests access to the notes. What access should be provided?
Option list.
A
provide access to the records by the Coroner in person
B
provide unrestricted access to the medical records by the coroner’s officers
C
provide a copy of the hospital records to the coroner or her officers
D
provide a medical report, but no access to the medical records
E
provide a copy of the letter to the GP about the recent admission
F
none of the above

17.         EMQ. Early pregnancy: diagnoses to exclude.
Lead-in.
The following scenarios relate to early pregnancy.
For each, select the diagnosis you most want to exclude.
Pick one option from the option list.
Each option can be used once, more than once or not at all.
Option list.
Complete miscarriage.
Incomplete miscarriage.
Missed miscarriage.
Pregnancy in a uterine horn.
Ectopic pregnancy.
OHSS.
Ovarian torsion.
Ovarian cyst accident.
Hydatidiform mole.
Listeriosis.
Toxoplasmosis.
Crohn’s disease
Ulcerative colitis.
Duodenal ulceration.
Pulmonary embolism.
Pneumothorax.
Coronary thrombosis.
None of the above.

Scenario 1.
A 35-year-old primigravida is seen in the EPU with vaginal bleeding and severe left iliac fossa pain. The pregnancy occurred after four cycles of IVF and embryo transfer was performed six weeks ago. Her β-hCG is >1,000 iu/l. An ultrasound scan showed an intra-uterine pregnancy of an appropriate size for the gestation. Normal fetal heart activity was noted. No adnexal masses were seen.
Scenario 2.
A 25-year-old woman with known PCOS is seen in the early pregnancy unit after an episode of slight vaginal bleeding. Her LMP was 10 weeks ago. An ultrasound scan shows an intra-uterine pregnancy with CRL of 6 mm. No fetal heart activity is seen.
Scenario 3.
A GP phones for advice. She is conducting her morning surgery. A nulliparous woman at 6 weeks’ gestation has returned from France where she has enjoyed the local food, particularly unpasteurised soft cheese and pork meats. She has presented with diarrhoea and mild abdominal pain. A β-hCG is 25 iu/l. She is concerned about listeriosis and toxoplasmosis, about which she has read.
Scenario 4.
A 30-year-old parous woman attends the EPU with vaginal bleeding and lower abdominal pain. An ultrasound scan shows a 30 mm. intra-uterine sac but no evidence of fetal heart activity.
Scenario 5.
 A 45-year-old para 6 is admitted to the A&E department with 6 weeks’ amenorrhoea. A β-hCG is positive. She complains of retrosternal pain and has a history of heartburn and acid reflux. Her BMI is 30. She smokes 40 cigarettes daily and has COAD.

18.         Early pregnancy complications.
Lead-in.
The following scenarios relate to early pregnancy. For each, select the most appropriate answer from the option list. Each option can be used once, more than once or not at all.
Option List.
A.          Admit as an emergency case.
B.           Counsel and arrange TVS in 1 week.
C.           Counsel and arrange TV colour Doppler scan.
D.          Counsel re expectant management.
E.           Explain diagnosis and counsel re MEUC and SEUC.
F.           Explain diagnosis and counsel re expectant management and MEUC and SEUC.
G.          Explain diagnosis and counsel re expectant management, MEUC and SEUC and refer to the EPU.
H.          Explain diagnosis and counsel re treatment options with accent on the relative merits of SEUC and refer to the EPU.
I.            Explain diagnosis and counsel re treatment options with accent on the relative merits of MEUC and refer to the EPU.
J.            Explain diagnosis and refer to the EPU for PUL protocol.
K.           Explain diagnosis and refer to the EPU for PUV protocol.
L.           Manage as ectopic pregnancy until proven otherwise.
M.         Arrange progesterone assay.
N.          Arrange AFC.
O.          Arrange AMH assay.
P.           Arrange serial hCG monitoring for 48 hours.
Q.          Administer anti-D immunoglobulin.
R.           Administer ergometrine 0.5 mg i.m.
S.           Prescribe mifepristone.
T.           Prescribe misoprostol for vaginal use.
U.          Continue with routine booking.
Abbreviations.
AFC.           antral follicle count.
AMH.         anti-Mullerian hormone.
CRL.           crown-rump length.
EPU.           early pregnancy unit.
FSH.           follicle stimulating hormone.
GTD.          gestational trophoblastic disease.
hCG.          human chorionic gonadotrophin
MEUC.      medical evacuation of uterine contents.
PUL.           pregnancy of unknown location.
PUV.          pregnancy of uncertain viability.
RM.            recurrent miscarriage.
SEUC.        surgical evacuation of uterine contents.
TVS.           trans-vaginal scan
USS.           ultrasound scan

Scenario 1.
A nulliparous woman attends the booking clinic at 8 weeks’ gestation. An ultrasound scan shows a missed miscarriage of a size commensurate with the gestation. What will be your management?
Scenario 2.
A nulliparous woman attends the booking clinic at 8 weeks’ gestation. An ultrasound scan shows a missed miscarriage of a size commensurate with the gestation. She has had two previous pregnancies; both resulted in 1st. trimester miscarriage. What will be your management?
Scenario 3.
A primigravid woman attends the A&E department with abdominal pain and vaginal bleeding. A home pregnancy test was +ve 1 week ago; the date of the LMP is uncertain. What will be your management?
Scenario 4.
A 40-year old woman is pregnant for the first time. Her periods have been erratic for 12 months and she has occasional hot flushes. She attends the A&E department with abdominal pain and vaginal bleeding. The bleeding is slight and her condition is good. An hCG is +ve and a TVS shows an incomplete miscarriage. What will be your management?
Scenario 5.
A 35-year-old woman has had two normal pregnancies. She attends the booking clinic after an unplanned conception. Her hCG is +ve. A TVS shows endometrial thickening but no evidence of intra-uterine pregnancy. No pelvic abnormality is seen. What will be your management?
Scenario 6.
A 35-year-old woman has had two normal pregnancies. She attends the booking clinic after an unplanned conception. Her hCG is +ve. A TVS shows a 15 mm. intra-uterine sac, but no fetus or yolk sac. What will be your management?
Scenario 7.
A 35-year-old woman has had two normal pregnancies. She attends the booking clinic after an unplanned conception. Her hCG is +ve. A TVS shows a 30 mm. intra-uterine sac, but no fetus. What will be your management?
Scenario 8.
A 35-year-old woman has had two normal pregnancies. She attends the booking clinic after an unplanned conception. Her hCG is +ve. A TVS shows an intra-uterine fetus with crown rump length of 5 mm., but no evidence of fetal heart activity. What will be your management?
 Scenario 9.
A 35-year-old woman has had two normal pregnancies. She attends the booking clinic after an unplanned conception. Her hCG is +ve. A TVS shows an intra-uterine fetus with crown rump length of 6 mm. Fetal heart activity is seen. What will be your management?
Scenario 10.
A 35-year-old woman attends the A&E department at 6 weeks’ gestation with pain and bleeding. She became pregnant after IVF. An ultrasound scan shows a viable intrauterine pregnancy of a size compatible with the gestation. What will be your management?

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