Tutorial 15th. August 2016

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15 August 2016.

68	EMQ. Cervical cytology, colposcopy and referral
69	EMQ. Obstetric cholestasis 1
70	EMQ. Labour 2

68.   EMQ. Cervical cytology, colposcopy and referral.

Abbreviations.

ALOs:            actinomyces-like organisms

ART:              antiretroviral therapy

ASCUS:          atypical squamous cells of undetermined significance.

BCE:              borderline change in endocervical cells

BCC:              borderline change in squamous cells

cART:            combination antiretroviral therapy, now preferred to the term “HAART”.

CIN:               cervical intraepithelial abnormality

CGIN:            cervical glandular intraepithelial abnormality

?GNE:            ? glandular neoplasia of endocervical type

?GNNC:         ? glandular neoplasia (non-cervical)

GUM clinic:  genito-urinary medicine clinic

HAART:         highly active antiretroviral therapy

HGD:             high-grade dyskaryosis (? invasive squamous carcinoma)

HGD?I:          high-grade dyskaryosis (? invasive squamous carcinoma)

HGDM:         high-grade dyskaryosis (moderate)

HGDS:           high-grade dyskaryosis (severe)

HPV:              human papilloma virus

HPVT:            HPV triage

HRHPV:         high-risk HPV

LBC:               liquid-based cytology

LGD:              low-grade dyskaryosis

LLETZ:           large loop excision of the transformation zone

MDT:             multi-disciplinary team

NEC:              normal endometrial cell

POP:              progesterone-only Pill

SCJ:                squamo-columnar junction

SIL:                squamous intraepithelial lesion

TZ:                 transformation zone

VaIN:             vaginal intraepithelial neoplasia

Lead-in.

The following questions relate to the management of cervical smears.

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.        management according to HRHPV triage

H.        repeat the test after giving an appropriate antibiotic

I.           repeat the test after removing her IUCD.

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

K.         repeat the test after treating the TZ with diathermy

L.          repeat the test after treating the TZ with cryocautery

M.      discharge from follow-up

N.        refer for colposcopy

O.        refer for colposcopy within 2 weeks

P.         refer for colposcopy within 8 weeks

Q.        refer for colposcopy within 12 weeks

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

S.         refer for cone biopsy

T.         refer for fractional curettage

U.        refer for “see and treat” LLETZ

V.        refer to GUM clinic

W.      recommend that she go back to America

X.         there is insufficient information to formulate a management plan

Y.         false

Z.         true

AA.    none of the above

BB.     age 24 years

CC.     age 24.5 years

DD.   age 25 years

Question 1.

At what age is the first invitation to have a smear test sent?

Option list.

A	20 years
B	22 years
C	24 years
D	24.5 years
E	25 years

Question 2.

Which of the following statements is used by the NHSCSP to justify not offering routine screening to younger women?

Option list.

A	most low-grade changes in younger women regress spontaneously
B	most high-grade changes in younger women regress spontaneously
C	HPV induced changes are common in younger women and screening would cause large numbers of unnecessary colposcopy referrals and be prohibitively expensive
D	colposcopic treatments may cause pre-term labour in subsequent pregnancies
E	there is no evidence that screening younger women reduces incidence of cervical cancer or resulting mortality.

Question 3.

How often should women of 30 have routine smear tests?

Option list.

A	every year
B	every 2 years
C	every 3 years
D	every 4 years
E	every 5 years

Question 4.

A woman of 30 years is due to have a routine smear. How long after the previous smear should the invitation be sent?

Option list.

A	34 months
B	36 months
C	58 months
D	60 months
E	none of the above

Question 5.

How often should women of 50 have routine smear tests?

Option list.

A	every year
B	every 2 years
C	every 3 years
D	every 4 years
E	every 5 years

Question 6.

A woman of 50 years is due to have a routine smear. How long after the previous smear should the invitation be sent?

Option list.

A	34 months
B	36 months
C	58 months
D	60 months
E	none of the above

Question 7.

Which, if any, of the following are grounds for continuing smear tests beyond the age of 64?

Option list.

A	no adequate screening test after the age of 50
B	no adequate screening test after the age of 55
C	no adequate screening test after the age of 60
D	patient’s request due to family history of fatal cervical cancer
E	presence of genital warts

Question 8.

Which, if any, of the following are grounds for smear tests in addition to routine tests?

Option list.

A	history of heavy cigarette consumption
B	1st. use of the combined oral contraceptive
C	diagnosis of genital warts involving the cervix
D	new sexual partner
E	multiple sexual partners

Question 9.

Which, if any, of the following are grounds for smear tests in addition to routine tests in the GUM clinic?

Option list.

A	1st. attendance at a GUM clinic
B	any  attendance at a GUM clinic with proven STI
C	diagnosis of genital warts involving the cervix
D	new sexual partner with history of STI
E	multiple sexual partners – simultaneous
F	multiple sexual partners – not simultaneous

Question 10.

Which, if any, of the following are true of cervical cytology as a means of diagnosing STIs?

Option list.

A	cervical cytology can be used to diagnose chlamydial infections
B	cervical cytology can be used to diagnose gonococcal infections
C	cervical cytology can be used to diagnose herpes
D	cervical cytology can be used to diagnose syphilis
E	cervical cytology can be used to diagnose trichomonal infections

Question 11.

Which of the following should be used in the initial investigation of the woman, younger than the age for inclusion in the NHSCSP programme, who presents with a three month history of intermenstrual and postcoital bleeding?

Option list.

A	inspection of the cervix using a speculum
B	inspection of the cervix using a colposcope
C	pregnancy test
D	screening for chlamydia
E	cervical smear

Question 12.

Which, if any, of the following statements are true with regard to HRHPV as primary screening.

Option list.

A	HRHPV is about 10% more sensitive than LBC in detecting borderline or worse changes
B	HRHPV is about 25% more sensitive than LBC in detecting borderline or worse changes
C	HRHPV detects > 70% of CIN2, CIN3 and invasive cancer
D	HRHPV detects > 90% of CIN2, CIN3 and invasive cancer
E	HRHPV is about 6% less specific in detecting borderline or worse changes

Question 13.

Approximately how much of the NHSCSP was covered by the six sentinel sites used to evaluate modern approaches to cervical screening?

Option list.

A	1%
B	5%
C	10%
D	15%
E	20%

Question 14.

Which of the following statements are true in relation to the data obtained from the six sentinel sites?

Option list.

A	16% of women with low-grade dyskaryosis were HRHPV –ve and returned to routine screening
B	26% of women with low-grade dyskaryosis were HRHPV –ve and returned to routine screening
C	45% of women with borderline changes were HRHPV –ve and returned to routine screening
D	65% of women with borderline changes were HRHPV –ve and returned to routine screening
E	colposcopy referral rates increased by > 60%

Question 15.

Which, if any, of the following statements are true in relation to the NHSCSP in the year ending 31 March 2015?

Statements.

A	85% of eligible women were screened in the year up to 31 March 2015
B	72% of eligible women aged 25-49 years were screened
C	78% of eligible women aged 50-64 years were screened
D	4.31 million women were invited for screening & 3.12 million women were tested
E	98% of women should receive their smear reports within 2/52, but only 91% did
F	3.2 million samples were examined by the laboratories
G	198,216 referrals were made to colposcopy, a 0.6% ↓ from the previous year
H	2.5% of smears were inadequate

Question 16.

Which, if any, of the following statements are true in relation to LBC and the traditional cervical smear?

Statements.

A	both involve drying the slide on which the smear is made in air by the person taking the smear
B	the sensitivity of LBC is superior
C	the specificity of LBC is superior
D	inadequate smears ↓ from about 9% with traditional smears to 1-2% with LBC
E	LBC is now the NHSCSP standard for cervical screening
F	HPV testing cannot be done on routine LBC samples

Question 17.

Lead in.

Which, if any, of the following statements are true in relation to inadequate smears?

A	inadequate smears are defined as those showing insufficient squamous cells
B	inadequate smears are defined as those showing inflammatory changes
C	a smear should not be defined as inadequate if there are borderline or dyskaryotic changes
D	a repeat LBC sample should be obtained within 1 month of an initial inadequate sample
E	a repeat LBC sample should be obtained within 2 months of an initial inadequate sample
F	a repeat LBC sample should be obtained after an initial inadequate sample, but not within 3 months
G	referral for colposcopy is required after 2 consecutive inadequate cervical smear reports
H	referral for colposcopy is required after 3 consecutive inadequate cervical smear reports
I	referral for colposcopy is required after 4 consecutive inadequate cervical smear reports
J	the appointment for initial colposcopy after inadequate smears should be within 6/52 of referral
K	the appointment for initial colposcopy after inadequate smears should be within 12/52 of referral
L	referral for colposcopy after inadequate smears is to exclude invasive cancer

Question 18.

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

Question 19.

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

Question 20.

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

Question 21.

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

Question 22.

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

Question 23.

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

Question 24.

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?

Question 25.

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

Question 26.

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?

Question 27.

A woman with no previous abnormal smears had a smear showing borderline changes. A repeat smear after 6 months was normal. A repeat smear after 3 years showed mild atypia. A repeat smear after 6 months was normal. A recent repeat smear, 3 years after the previous one, showed borderline changes. What management will you suggest?

Question 28.

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

Question 29.

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

Question 30.

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

Question 31.

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

Question 32.

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

Question 33.

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

Question 34.

A 30-year-old woman with no previous abnormal smears has had a smear showing ? glandular neoplasia. She is nulliparous and would like to have children. Colposcopic appearances suggest high-grade CGIN. What management will you suggest?

Question 35.

A 50-year-old woman with no previous abnormal smears has had a smear showing ? glandular neoplasia. Colposcopic appearances suggest high-grade CGIN. What management will you suggest?

Question 36.

A 50-year-old woman with no previous abnormal smears has had a smear showing ? glandular neoplasia. Colposcopic appearances suggest high-grade CGIN. An appropriate excisional biopsy is taken which shows no abnormality. What management will you suggest?

Question 37.

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

Question 38.

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

Question 39.

A woman with no previous abnormal smears and no symptoms has had a smear with a normal result. Clinical examination was normal, but contact bleeding was noted when the smear was taken. The Practice Nurse who took the smear phones you for advice about her management. What advice will you give?

Question 40.

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?

Question 41.

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?

Question 42.

Which, if any, of the following statements are true in relation to women who are HIV +ve compared to those who are HIV -ve?

A	there is an increased incidence of false –ve smear reports
B	there is an increased incidence of false +ve smear reports
C	the prevalence of SILs is 10-20%, 10 times higher than for HIV-ve women
D	the prevalence of SILs is 20-40%, 10 times higher than for HIV-ve women
E	HIV +ve women taking HAART have higher rates of abnormal cytology than HIV –ve women
F	HAART may reduce the prevalence of squamous intraepithelial lesions
G	LGD is less likely to regress
H	LGD is more likely to regress
I	HGD responds less well to standard treatments
J	HGD responds better to standard treatments
K	Close co-operation between the HIV medical team and colposcopists / smear takers is essential

Question 43.

A woman recently diagnosed as HIV +ve has had a smear with a normal result. Previous smears have been normal. Which, if any, of the following statements are true?

A	twice yearly smears should be arranged
B	annual smears should be arranged
C	colposcopy should be arranged if resources permit as part of the initial assessment
D	annual colposcopy should be arranged if resources permit
E	ablation of low-grade CIN should be offered as such lesions are more likely to progress than in HIV –ve women
F	surgical removal of the cervix should be offered if high-grade CIN is diagnosed
G	screening should continue until at least the age of 75
H	women with good response to HAART and normal cytology can safely return to routine screening

Question 44.

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?

Question 45.

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?

Question 46.

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?

Question 47.

Which, if any, of the following statements are true about women who have been treated for CIN compared to women who have not been treated?

A	their risk of developing cervical cancer is increased by a factor of 2 – 5 compared to women who have not been treated
B	women should be returned to community-based recall
C	women should have a cervical sample taken for cytology at 6 months, but only if the excision margins were clear. Where the excision margin was, or may have been involved, colposcopy should be done at 6 months
D	if the 6 months cytology is normal, borderline or low-grade and the HRHPV test is –ve, women should return to routine recall based on their age
E	if the 6 months cytology is normal, borderline or low-grade and the HRHPV test is –ve, women should have repeat cytology at 3 years, regardless of their age
F	if the 6 months cytology shows changes worse than low-grade, colposcopy should be done and HRHPV testing is not required
G	if “test of cure” cytology is done in hospital, it should be in a cytology clinic, not the colposcopy clinic

Question 48.

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

Question 49.

Which of the following statements are true and which false in relation to treatment of CIN?

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

b.  the Tz must be seen in its entirety if ablative techniques are to be used

c.   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.

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

e.  the “see and treat” policy should no longer be used.

f.   excisional treatments should be used in women > 50 years.

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

e.  the initial follow-up examination after treatment for CIN should be with colposcopy plus cytology.

f.   a failure to achieve negative results in the year after treatment means cone biopsy 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.

Question 50

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

Question 51.

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?

Question 52.

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?

Question 53.

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?

Question 54.

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

Question 55.

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?

Question 56.

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

Question 57.

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?

Question 58.

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?

Question 59.

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

Question 60.

A woman has FIGO stage 1a1 cervical cancer. She wishes to retain her fertility. Which of the following treatments should be offered?

A	brachytherapy
B	cone biopsy
C	cryocautery
D	laser ablation
E	LLETZ
F	radical trachelectomy
G	simple trachelectomy

Question 61.

A woman has local excision for early cervical cancer. What follow-up should be arranged by the NHSCSP?

A	colposcopy and smears six monthly for 1 year, then annually for 9 years
B	colposcopy and smears six monthly for 2 years, then annually for 8 years
C	smears six monthly for 1 year, then annually for 9 years
D	smears six monthly for 2 years, then annually for 8 years
E	smears six monthly for 5 years, then annually for 5 years
F	none of the above

Question 62.

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

Question 63.

Which, if any, of the following statements are true in relation to pregnancy?

A	routine smear tests should be deferred until after delivery
B	colposcopy requires more expertise than in the non-pregnant
C	all smears suggesting CIN should have initial colposcopic assessment in late 1st. or early 2nd. trimester
D	women with low-grade changes who have been referred to colposcopy because of a +ve HPV test can had colposcopy delayed until after delivery
E	if CIN1 is diagnosed, follow-up can be delayed until after delivery
F	“test of cure” appointments after treatment of CIN 2 or 3 can be deferred until after delivery
G	follow-up assessment after treatment of CGIN can be left until after the delivery if the excision margins were disease-free.

69.   EMQ. Obstetric cholestasis 1

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?

66.   EMQ. Labour 2.

Lead in.

For each scenario below, choose the most appropriate answer from the option list.

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

CTG.      cardio-tocograph.

FBS.       fetal scalp-blood sample.

FHR.      fetal heart rate.

Option List.

1. start protocol for severe hypertension
2. allow labour to progress and re-assess in 30 minutes
3. increase syntocinon infusion rate.
4. increase syntocinon infusion rate and encourage effective pushing.
5. give misoprostol.
6. stop syntocinon, give O₂,perform left-lateral tilt and re-assess in 30 minutes
7. start intra-uterine pressure monitoring
8. start STAN monitoring
9. perform fetal blood sampling
10. arrange category 1 Caesarean section
11. arrange category 2 Caesarean section
12. arrange category 3 Caesarean section
13. arrange category 4 Caesarean section
14. perform ventouse delivery
15. perform forceps delivery
16. perform breech extraction
17. perform external cephalic version
18. perform internal podalic version
19. none of the above

Scenario 1.

A 30-year-old primigravida has labour induced at 39 weeks because of pre-eclampsia.

Her blood pressure had been moderately raised since 36 weeks and a 24-hour urine collection showed 4 gm. protein. (Do you know the cut-offs for mild/moderate/sever hypertension? Answer below.)

ARM was done when the cervix was 4 cm. dilated and an oxytocin infusion was started 2 hours later as the contractions were infrequent.

She reached the 2^nd. stage 6 hours after the ARM. You are called to see her 30 minutes later as the CTG shows variable decelerations and loss of baseline variability.

The fetal head is not palpable abdominally and vaginal examination shows a cephalic presentation 1 cm. below the spines and the position DOA.

What will be your management?

Scenario 2.

A 40-year-old grande-multip with BMI 35 goes into labour at 38 weeks. She decides to have an epidural as she has not had one before and would like the experience. An effective block has been sited. She reaches the second stage 4 hours after admission. The epidural is not topped up and active pushing starts 30 minutes later. After 1 hour a FHR deceleration to 60 b.p.m. with slow recovery and loss of variability is noted. On abdominal examination, the head is < 1/5 palpable. Vaginal examination shows the head to be just above the ischial spines with moderate caput and moulding. What will be your management?

Scenario 3.

A 29-yr-old woman with IDDM is admitted at 36 weeks’ gestation with ketoacidosis and a blood sugar of 15 mmol/l. A CTG is done and the FHR is 180 b.p.m. with loss of variability and variable decelerations. What will be your management?

Scenario 4.

A 30-year-old woman with a previous normal delivery is admitted in labour for a planned vaginal breech delivery. On admission the cervix is 6 cm. dilated and a flexed breech presents 2 cm. below the spines. Two hours later the fetal heart rate rises to 160 b.p.m. with loss of variability and variable decelerations. Fresh meconium is passed. What will be your management?

Scenario 5.

A 35-year-old woman with a previous normal delivery is admitted in labour for a planned vaginal delivery. On admission the cervix is 6 cm. dilated and a cephalic presentation is confirmed with the presenting part 2 cm. below the spines. Two hours later the cervix is 9 cm. dilated and the presenting part is on the perineum. The fetal heart rate has risen to 150 b.p.m. with loss of variability and variable decelerations. Fresh meconium is passed. A FBS shows a pH of 7.3. What will be your management?

Scenario 6.

A 35-year-old woman with a previous normal delivery is admitted in labour. On admission the cervix is 6 cm. dilated and a cephalic presentation is confirmed with the presenting part 2 cm. below the spines. Two hours later the cervix is fully dilated and the presenting part is on the perineum. The fetal heart rate has risen to 150 b.p.m. with loss of variability and variable decelerations. Fresh meconium is passed. A FBS shows a pH of 7.2. What will be your management?

Scenario 7.

A 20 year-old nulliparous woman is admitted in labour at 33+5 weeks’ gestation. She reaches the 2^nd. stage after 12 hours with the head in an OA position and 2 cm. below the spines. She becomes exhausted after 2 hours of active pushing. The FHR shows variable decelerations + loss of variability. A FBS shows a pH of 7.22. What will be your management?

Scenario 8.

A 20 year-old nulliparous woman is admitted in labour at 39+5 weeks’ gestation. An epidural is sited at her request when her cervix is 4 cm. dilated but a dural tap occurs. She complains of headache. What will be your management?