Thursday, 18 August 2016

Tutorial 18th. August 2016



18 August 2016.

71
EMQ. Obstetric cholestasis diagnosis & management
72
EMQ. DSDs. AIS, Kallman’s & Swyer’s syndromes
73
EMQ. Caesarean section. NICE CG 132.
74
SBA. Idiopathic intracranial hypertension in pregnancy

In addition to the following questions, we will discuss the CPD answers from the TOG article relating to intracranial hypertension. They are open access, so download and answer them. CPD questions. TOG. Volume 16. 2.

71.         EMQ. Obstetric cholestasis. (OC).
Lead-in.
The following scenarios relate to the definition, diagnosis and management.
Some of the answers are True / False, otherwise 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
GTG:     RCOG’s Green-top Guideline No. 43. April 2011.
OC:        obstetric cholestasis.
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.

72.   EMQ.
AIS, MRKH and Swyer’s syndrome
Lead-in.
The following scenarios relate to disorders of sexual development.
Pick the option from the option list that best fits each scenario.
Each option can be used once, more than once or not at all.

Option list 1.
A.        has a uterus of normal size for her age.
B.         has a uterus that is hypoplastic for her age.
C.         has a vestigial uterus (anlagen).
D.        has no uterus.
E.         commonly has esthiomene
F.         I don’t know and I don’t care.
G.        the question makes no sense.
H.        none of the above.

Scenarios.
a.     a girl with congenital adrenal hyperplasia at the start of puberty.
b.     a girl with complete androgen insensitivity syndrome at the start of puberty.
c.      a girl with a disorder of sexual differentiation at the start of puberty.
d.     a girl with Kallmann’s syndrome at the start of puberty.
e.     a girl with Laurence-Moon-Biedl syndrome at the start of puberty.
f.      a girl with Mayer-Rokitansky-Kuster-Hauser syndrome at the start of puberty.
g.     a girl with partial androgen insensitivity syndrome at the start of puberty.
h.     a girl with Prader-Willi syndrome at the start of puberty.
i.      a girl with Swyer’s syndrome at the start of puberty.
j.      a girl with Turner’s syndrome at the start of puberty.

73.   EMQ. Caesarean section. NICE CG 132.
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.

74.   EMQ.
Idiopathic intracranial hypertension.
In addition to the following questions, we will discuss the CPD answers from the TOG article. They are open access, so download and answer them. CPD questions. TOG. Volume 16. 2.
Abbreviations.
CSF:         cerebro-spinal fluid
CT scan:  computed tomography scan
IIH:           idiopathic intracranial hypertension
Scenario 1.
Lead-in
Which  of the following statements is true in relation to IH?
Option List
A.       
the aetiology is unknown
B.       
is associated with severe pre-eclampsia
C.       
is due to obesity
D.       
is due to impaired ventricular drainage
E.        
is due to increased production of CSF in the thoraco-lumbar spine
Scenario 2
Which of the following statements best fits with the prevalence of IIH in women of childbearing age?
Option List
A.       
the female: male ratio is 2: 1
B.       
the female: male ratio is 1: 2
C.       
the prevalence is about 1 in 100,000 in those of normal weight, rising by a factor of about 20 in the obese
D.       
the incidence trebles in pregnancy
E.        
the incidence falls to normal in the 6 weeks after delivery
Scenario 3.
Which  is the most common presenting symptom in IIH?
Option List
A.       
exophthalmos
B.       
headache
C.       
papilloedema
D.       
seizures
E.        
visual disturbance
Scenario 4.
Which of the following are features of the headache associated with IIH?
Features
A.       
steady, occipital pain with overlying scalp tenderness & sensitivity
B.       
throbbing, retro-orbital pain that may worsen with eye movement
C.       
accompanied by photophobia
D.       
accompanied by auditory hallucinations
E.        
accompanied by visual disturbance
Option List
1
A + C + D + E
2
A + C + E
3
B + C + D + E
4
B + C + E
5
B + E
Scenario 5.
Which, if any, of following are found with IIH?
Features
A.       
papilloedema
B.       
reduced colour vision
C.       
reduced visual acuity
D.       
palsy of the cranial nerve VI
E.        
none of the above
Option List
1
A + B + C + D
2
A + C + D
3
B + C + D
4
B + C + E
5
E
Scenario 6.
Which of the following statements is true
Option List
A.       
visual symptoms are directly proportional to the degree of papilloedema
B.       
visual symptoms are indirectly proportional to the degree of papilloedema
C.       
visual symptoms worsen exponentially with the degree of papilloedema
D.       
visual symptoms are independent of the degree of papilloedema
E.        
none of the above
Scenario 7.
The features of IIH were described by Dr. X in and subsequently used to create a list of diagnostic criteria by Dr. Smith in 1985.  What was the name of Dr. X?
Option List
A.       
Dr. Beano
B.       
Dr. Dandy
C.       
Dr. Fop
D.       
Dr. Fineanddandy
E.        
none of the above.
Scenario 8.
What are the diagnostic criteria named eponymously after Dr. X?
There is no option list – add what you know.
Scenario 9.
What are the characteristic features of the CSF?
Features
A.       
pressure > 100 mmH2O
B.       
pressure > 250 mmH2O
C.       
↑ angiotensin
D.       
↑ protein
E.        
↑ white blood cells
Option List
1
A  + C + D + E
2
B + C + D + E
3
A + C + D
4
B + C + D
5
A
6
B


Scenario 10.
What imaging is recommended?
Option List
A.       
skull x-ray
B.       
CT scan
C.       
MR scan
D.       
CT scan with MR added in atypical cases
E.        
none of the above.
Scenario 11.
Which of the following are described in relation to CT scanning?
Option List
A.       
the fetal radiation dose is below the recommended maximum in a maternal head scan
B.       
the fetal radiation dose is close to the recommended maximum in a maternal head scan
C.       
gadolinium contrast media cross the placenta and have been teratogenic in animal studies
D.       
the European Society of Radiology guidelines say that gadolinium should not be used in pregnancy
E.        
none of the above.
Scenario 12.
Which of the following are described in relation to IIH?
Option List
F.        
papilloedema
G.       
severe visual loss in up to 20% of cases
H.       
central vision is preserved
I.         
enlargement of the blind spot
J.         
loss of peripheral field acuity
Scenario 13.
How should visual function be monitored?
Option List
A.       
fundoscopy
B.       
disc imaging
C.       
quantitative serial perimetry
D.       
qualitative serial perimetry
E.        
radio-isotope retinal mapping
Scenario 14.
Which of the following are accurate in relation to the effect of IIH on pregnancy and pregnancy on IIH?
Option List
A.       
TOP should be recommended if there is any evidence of visual loss as this can deteriorate dramatically even with good monitoring
B.       
PET is more common
C.       
IIH makes pregnancy less common due to pituitary pressure and ↓ secretion of FSH & LH
D.       
pregnancy is a risk factor for IIH and visual outcomes are worse
E.        
IIH has no averse pregnancy outcomes and TOP is not indicated
Scenario 15.
Which of the following statements are true in relation to management of IIH in pregnancy?
Option List
A.       
the management is the same as in the non-pregnant
B.       
the aims of management are symptom control and preservation of vision
C.       
dietary changes aiding weight loss are important in the overweight
D.       
analgesics and diuretics are prescribed
E.        
repeated lumbar puncture, CSF shunts and optic nerve sheath fenestration are used.
Scenario 16.
Which of the following statements is most apt regarding the safest mode of delivery?
Option List
A.       
Caesarean section is the preferred mode of delivery to prevent cerebellar herniation
B.       
MOD should be determined on obstetric grounds in most cases
C.       
vaginal delivery is acceptable, but “pushing” should be discouraged
D.       
neurological symptoms and patient preference should determine MOD in women with CSF shunts
E.        
leave it all to Mother Nature.
Scenario 17.
With regard to acetazolamide, which of the following are true?
Option List
A.       
it deduces CSF production by choroid plexus
B.       
it has been linked to teratogenesis in animals
C.       
is not used for IIH in pregnancy
D.       
women who conceive on acetazolamide should be advised to have TOP
E.        
it should not be used by women who breastfeed as the concentration in breast milk is high and can have adverse effects on neonatal renal blood flow
Scenario 18.                      
What imaging is recommended?
Option List
F.        
skull x-ray
G.       
CT scan
H.       
MR scan
I.         
CT scan with MR added in atypical cases
J.         
none of the above.


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