Thursday 25 February 2016

Tutorial 25th. February 2016


Website.
25 February 2016.

72
SBA. Appendicitis in pregnancy
73
EMQ. Caesarean section and NICE’s CG132
74
SBA. Prophylactic antibiotics & Caesarean section
75
EMQ. Puerperal psychosis and mental health
76
EMQ. Group B streptococcus & neonate
77
EMQ. Gestational trophoblastic disease

72.   SBA. SBA. Appendicitis in pregnancy
Abbreviations.
AIP
Appendicitis in pregnancy
CRP
C reactive protein
CT
computed tomography, also known as computerised tomography
RLQP
right lower quadrant pain
RUQP
right upper quadrant pain
Question 1.
Lead-in
What is the approximate incidence of appendicitis in pregnancy?
Option List
A.       
1 in 500
B.       
1 in 1,000
C.       
1 in 2,000
D.       
1 in 5,000
E.        
1 in 10,000
Question 2.
Lead-in
When is appendicitis in pregnancy most common?
Option List
A.       
first trimester
B.       
second trimester
C.       
trimester
D.       
1st. and 2nd. stages of labour
E.        
in the hours after the 3rd. stage of labour
F.        
during the puerperium
Question 3.
Lead-in
What eponymous title is given to the surface marker for the appendix?
Option List
A.       
McBarney’s point
B.       
MacBurney’s point
C.       
McBurney’s point
D.       
MacBorney’s point
E.        
McBorney’s point
Question 4.
Lead-in
Where is the point referred to in the above question?
Option List
A.       
1/3 of the way along the line joining the anterior superior iliac spine and umbilicus
B.       
1/2 of the way along the line joining the anterior superior iliac spine and umbilicus
C.       
2/3 of the way along the line joining the anterior superior iliac spine and umbilicus
D.       
1/3 of the way along the line joining the left and right anterior superior iliac spines
E.        
1/2 of the way along the line joining the left and right anterior superior iliac spines
Question 5.
Lead-in
Which, if any, of the following statements are true about the person after whom the point in the above questions is named?
Statements
A.       
he spent 2 years as a postgraduate working in Berlin, London, Paris and Vienna
B.       
he was Professor of surgery at the Roosevelt hospital, New York from 1889 to 1894
C.       
he presented his classical paper on appendicitis to the NY Surgical Society in 1889
D.       
he was a transvestite
E.        
he died of a heart attack while on a hunting trip
Question 6.
Lead-in.
Pick the best option from the list below in relation to right lower quadrant pain in AIP in the pregnant and non-pregnant.
Option List
A
comparative figures for the pregnant and non-pregnant are unknown due to the rarity of appendicitis in pregnancy
B
RLQP is as common in the pregnant as in the non-pregnant
C
RLQP is less common in the pregnant
D
RLQP is more common in the pregnant
E
RLQP is rare in pregnancy
Question 7.
Lead-in.
Pick the best option from the list below in relation to right upper quadrant pain in AIP in the pregnant and non-pregnant.
Option List
A
comparative figures for the pregnant and non-pregnant are unknown due to the rarity of appendicitis in pregnancy
B
RUQP is ½ as common in the pregnant as in the non-pregnant
C
RUQP is as common in the pregnant as in the non-pregnant
D
RUQP is twice as common in the pregnant as in the non-pregnant
E
RUQP is four times as common in the pregnant as in the non-pregnant
Question 8.
Lead-in.
Pick the best option from the list below in relation to nausea in AIP in the pregnant and non-pregnant.
Option List
A
comparative figures for the pregnant and non-pregnant are unknown due to the rarity of appendicitis in pregnancy
B
nausea is as common in the pregnant as in the non-pregnant
C
nausea is less common in the pregnant
D
nausea is more common in the pregnant
E
nausea is rare in pregnancy
Question 9.
Lead-in.
Which condition did CMACE say should be excluded in women presenting acutely with gastrointestinal symptoms?
Option List
A
aortic dissection
B
appendicitis
C
Caesarean section scar pregnancy
D
ectopic pregnancy
E
pancreatitis
F
ovarian torsion
Question 10.
Lead-in.
Pick the best option from the list below in relation to abdominal guarding in AIP in the pregnant and non-pregnant.
Option List
A
comparative figures for the pregnant and non-pregnant are unknown due to the rarity of appendicitis in pregnancy
B
abdominal guarding is as common in the pregnant as in the non-pregnant
C
abdominal guarding is less common in the pregnant
D
abdominal guarding is more common in the pregnant
E
abdominal guarding is rare in pregnancy
Question 11.
Lead-in.
Pick the best option from the list below in relation to rebound tenderness in AIP in the pregnant and non-pregnant.
Option List
A
comparative figures for the pregnant and non-pregnant are unknown due to the rarity of appendicitis in pregnancy
B
rebound tenderness is as common in the pregnant as in the non-pregnant
C
rebound tenderness is less common in the pregnant
D
rebound tenderness is more common in the pregnant
E
rebound tenderness is rare in pregnancy
Question 12.
Lead-in.
Pick the best option from the list below in relation to fever in AIP in the pregnant and non-pregnant.
Option List
A
comparative figures for the pregnant and non-pregnant are unknown due to the rarity of appendicitis in pregnancy
B
fever is as common in the pregnant as in the non-pregnant
C
fever is less common in the pregnant
D
fever is more common in the pregnant
E
fever is rare in pregnancy
Question 13.
Lead-in
How useful is the finding of leucocytosis in making the diagnosis of AIP?
Option List
A.       
sine qua non
B.       
very useful
C.       
not very useful
D.       
I don’t know
Question 14.
How useful is the finding of a raised CRP level the diagnosis of AIP?
Option List
A.       
sine qua non
B.       
very useful
C.       
not very useful
D.       
I don’t know
Question 15.
Lead-in
What are the ultrasound features of appendicitis?
Option List
A
appendix with diameter > 0.6 mm.
B
appendix with diameter > 1 cm.
C
blind-ending tubular structure
D
non-compressible tubular structure
E
none of the above
Question 16.
Lead-in
What figures do W&M give for sensitivity & specificity for US diagnosis of appendicitis?
Option List

Sensitivity
Specificity
A
≥65%
≥80%
B
≥75%
≥85%
C
≥86%
≥97%
D
≥91%
≥98%
E
≥95%
≥95%
Question 17.
Lead-in
Which, if any, of the following statements are true about CT scanning for the diagnosis of AIP?
Option List
A
CT scanning has sensitivity > 85% and specificity >95%
B
CT scanning exposes mother and fetus to radiation doses of little concern
C
CT scanning has replaced ultrasound scanning for AIP
D
CT scanning is not of proven value after inconclusive ultrasound scanning
E
CT scanning is of proven value and most useful  after inconclusive ultrasound scanning
Question 18.
Lead-in
Which, if any, of the following statements are true about MRI scanning for the diagnosis of AIP?
Option List
A
MRI scanning has sensitivity > 90% and specificity >97%
B
MRI scanning exposes mother and fetus to radiation doses of little concern
C
MRI scanning has replaced ultrasound scanning for AIP
D
MRI scanning is not of proven value after inconclusive ultrasound scanning
E
MRI scanning is of proven value and most useful  after inconclusive ultrasound scanning
Question 19
Lead-in
Which, if any, of the following statements are true about the complications of AIP?
Option List
A
fetal loss rate in uncomplicated AIP is about 1.5%
B
fetal loss rate in AIP complicated by peritonitis is about 6%
C
fetal loss rate in AIP complicated by perforation of the appendix is up to 36%
D
pre-term delivery rates increase in AIP complicated by perforation of the appendix
E
a low level of suspicion should apply to the diagnosis of AIP in relation to surgical intervention
Question 20
Lead-in
Which, if any, of the following statements are true about surgery for AIP?
Option List
A
laparotomy should be done through a grid-iron incision with the mid-point the surface marker for the appendix in the right iliac fossa
B
laparotomy should be done through a right paramedian incision starting at the level of the umbilicus
C
about 35% of laparotomies show no evidence of appendicitis
D
the appendix should be removed even if it looks normal
E
antibiotic therapy is an alternative to surgery in early cases of AIP
Question 21
Lead-in
Which, if any, of the following statements are true about surgery for AIP?
Option List
A
laparotomy should be done through a grid-iron incision with the mid-point the surface marker for the appendix in the right iliac fossa
B
laparotomy should be done through a right paramedian incision starting at the level of the umbilicus
C
about 35% of laparotomies show no evidence of appendicitis
D
the appendix should be removed even if it looks normal
E
antibiotic therapy is an alternative to surgery in early cases of acute AIP
Question 22
Lead-in
Which, if any, of the following statements are true about surgery for AIP?
Option List
A
laparoscopic appendicectomy is an acceptable alternative to laparotomy, but only in the 1st. trimester
B
laparoscopic appendicectomy is an acceptable alternative to laparotomy, but only in the 1st. & 2nd. trimesters
C
laparoscopic appendicectomy is an acceptable alternative to laparotomy, at all gestations
D
there is evidence that laparoscopic appendicectomy is associated with doubling of the rate of fetal loss

73    SBA. Caesarean section and NICE’s CG132
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.

74    SBA. Prophylactic antibiotics & Caesarean section
For each scenario, pick the best answer from the option list.
Scenario 1.
What % of women will have infection after C. section?
Option list.
A
<5 %
B
5 – 9.9%
C
10 – 19.9%%
D
> 20%
Scenario 2.
Which, if any, of the following statements are correct about who should be offered prophylactic  antibiotics for Cs?
Option list.
A
all women
B
women with known predisposition to infection – e.g. diabetes
C
women with ruptured membranes for > 24 hours
D
women who are carriers of Gp B streptococcus
E
women who
Scenario 3.
When should prophylactic antibiotics be administered?
Option list.
A
administer 6 hours before skin incision
B
administer 12 hours before skin incision
C
administer with skin incision
D
administer after cord clamping
E
none of the above
Scenario 4.
Which antibiotic should be used?
Option list.
A
amoxicillin + metronidazole i.m.
B
antibiotic effective against local organisms most likely to cause wound infection
C
antibiotic effective against endometritis, UTI & wound infection
D
antibiotic effective against Gp. B streptococcus.
E
none of the above
Scenario 5.
Which antibiotic does NICE say should not be used and why?
Option list.
A
amoxicillin
B
co-amoxiclav
C
flucloxacillin
D
rifampicin
E
streptomycin

75    SBA. Puerperal psychosis and mental health
Puerperal mental illness.
Lead-in.
The following scenarios relate to puerperal mental illness.
Pick one option from the option list.
Each option can be used once, more than once or not at all.
Option list.
a.         arrange admission to hospital under Section 5 of the Mental Health Act
b.         send a referral letter to the perinatal psychiatrist requesting an urgent appointment.
c.          send an e-mail to the perinatal psychiatrist requesting an urgent appointment.
d.         phone the community psychiatric team.
e.         phone the on-call psychiatrist.
f.          arrange to see the patient in the next ante-natal clinic.
g.         arrange to see the patient urgently.
h.         send a referral letter to the social services department.
i.           phone the fire brigade.
j.           phone the police.
k.         there is no such thing.
l.           4 weeks
m.       6 weeks
n.         12 weeks
o.         26 weeks
p.         1 year
q.         <1%
r.          1-5%
s.          5-10%
t.          10-20%
u.         25%
v.         50%
w.       60%
x.         70%
y.         80%
z.          True
aa.     False
bb.     none of the above.
Scenario 1
What is the internationally agreed classification for postpartum psychiatric disease?
Scenario 2
What time limits does DSM-IV use for postpartum psychiatric disorders?
Scenario 3
What time limits does ICD-10 use pro postpartum psychiatric disorders?
Scenario 4
What clinical classification would you use in a viva or SAQ?
Scenario 5
What is the incidence of suicide in relation to pregnancy and the puerperium?
Scenario 6
What are the main conditions associated with suicide in pregnancy and the postnatal period?
Scenario 7
Most suicides occur in single women of low social class who have poor education. True / False
Scenario 8
The preferred method of suicide reported in recent MMRs was drug overdose.  True / False.
Scenario 9
When are women with Social Services involvement particularly at risk of suicide.
Scenario 10
Which women have the highest risk for puerperal psychosis and what is the risk?
Scenario 11.
What is the risk of puerperal psychosis for a primigravida with BPD?
Scenario 12
What is the risk of PP in a woman with no history of psychiatric illness but who has a FH of PP?
Scenario 13
Should screening include the identification of women with no history of psychiatric illness but who has a FH of PP?
Scenario 14
What do the Confidential Enquiries into Maternal Deaths say about the use of the term “postnatal depression”?
Scenario 15
Women with schizophrenia have a ≥ 25% risk of puerperal recurrence. True / False
Scenario 16
If lithium therapy for BPD is stopped in pregnancy, there is an increased risk of severe puerperal illness. True / False.
Scenario 17
You are the on-call SpR for obstetrics. A woman has just had a normal delivery of a 30 week baby that requires resuscitation. The mother says that the baby must be left alone and not resuscitated. The paediatric SpR and midwives are uncertain about what to do. What action will you take?
Scenario 18
You are the on-call SpR for obstetrics. The midwife on the postnatal ward phones for advice. A primigravida who delivered yesterday has stated that the baby is not hers and is refusing to care for it. What action will you take?
Scenario 19
You are the on-call Consultant in O&G. The community midwife has phoned for advice. She was asked to visit a primiparous woman who had a normal delivery seven days before. The husband reports that she has struck him several times. The woman tells her that voices have informed her that this man is not her husband and that she should drive him away in case he rapes her. What action will you take?
Scenario 20
You are the on-call Consultant in O&G. The community midwife has phoned. She has just been phoned by a woman who had a Caesarean section for breech presentation four weeks ago. She has been told by God that breech babies are the spawn of the Devil and she is going to the local multi-storey car park to jump off with the baby so that the baby cannot grow up and harm people and so that she cannot have more Devil babies. What action will you advise?

76    EMQ. Group B streptococcus
Lead-in.
The following scenarios relate to Group B Streptococcal disease.
Pick one option from the option list.
Each option can be used once, more than once or not at all.
Abbreviations.
EOGBS:         early-onset GBS disease.
GBS:              Group B streptococcus.
IAP:               intrapartum antibiotic prophylaxis.
Option list.
1.       Streptococcus agaractiae
2.       Streptococcus intergalacticae
3.       Streptococcus agalactiae
4.       Streptococcus ubernastiae
5.       Lancelot
6.       Lanceforth
7.       Lanceford
8.       Landscape
9.       0.01%
10.   0.02%
11.   0.023%
12.   0.025%
13.   0.05%
14.   0.1%
15.   0.5%
16.   0.53%
17.   0.54%
18.   0.6%
19.   0.63%
20.   0.75%
21.   0.9%
22.   1%
23.   2%
24.   2.3%
25.   2.4%
26.   2.5%
27.   5%
28.   10%
29.   15%
30.   20%
31.   25%
32.   26.3%
33.   21%
34.   30%
35.   35%
36.   1
37.   2
38.   3
39.   5
40.   6
41.   9
42.   10
43.   True
44.   False
45.   you are driving me mad with all these percentages

Scenario 1.
What is the scientific name for GBS?
Scenario 2.
Which animal is the main reservoir of GBS in relation to neonatal GBS?
Scenario 2.
What system is used for grouping streptococci?
Scenario 3.
Where does GBS disease feature in the list of serious early-onset neonatal infection?
Scenario 4.
What is the upper limit in days for time of onset in the definition of “early-onset” disease?
Scenario 5.
GBS is a gram-negative, capsulated organism.
Scenario 6.
What is the incidence of EOGBS in the UK in the babies of women who have not been screened for GBS or had IAP?
Scenario 7
What is the incidence of EOGBS in the babies of American women who have had antenatal GBS screening and IAP if screen +ve?
Scenario 8
What is the mortality rate of EOGBS in the UK?

77    SBA. Gestational Trophoblastic Disease (GTD)
Lead-in.
The following scenarios relate to GTD. For each, select the number 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.
Option list.
A.       
100%.
B.       
20%.
C.       
15%.
D.       
10%.
E.        
5%.
F.        
2.5%.
G.       
1.5%.
H.       
0.5%.
I.         
1 in 35.
J.         
1 in 55.
K.        
1 in 65.
L.        
1 in 700.
M.     
1 in 1,000.
N.       
Ö64.
O.      
pr2.
P.        
increased.
Q.      
reduced.
R.       
increased by a factor of 2.
S.        
increased by a factor of 5.
T.        
increased by a factor of 10.
U.       
increased by a factor of 20.
V.       
increased by a factor of 30.
W.     
increased by a factor of > 100.
X.        
hydatidiform mole, both partial and complete.
Y.        
hydatidiform mole, both partial and complete and placental site tumour.
Z.        
partial mole, complete mole, invasive and metastatic mole, choriocarcinoma, placental site trophoblastic tumour and epithelioid trophoblastic tumour.
AA.   
choriocarcinoma invasive and metastatic mole and epithelioid trophoblastic tumour.
BB.   
true
CC.   
false
DD.  
None of the above.
Abbreviations.
GTD:     gestational trophoblastic disease
GTN:     gestational trophoblastic neoplasia.
PSTT:    placental site trophoblastic tumour

Scenario 1.
What is the incidence of GTD in the UK?
Scenario 2
What is the difference between GTD and GTN?
Scenario 3
A woman had a complete mole in her first pregnancy. She is pregnant for the second time. What is the risk that it is another molar pregnancy?
Scenario 4.
A woman has had two molar pregnancies. What is the risk of molar pregnancy if she becomes pregnant again?
Scenario 5
A woman has had three molar pregnancies. What is the risk of molar pregnancy if she becomes pregnant again?
Scenario 6
Cystic placental spaces in the placenta and a ratio of transverse to anterioposterior
measurements of the gestation sac < 1.5 are strongly suggestive of a partial mole.  True / False
Scenario 7.
What is the risk of persistent GTD after a complete mole?
Scenario 8.
 What is the risk of requiring chemotherapy after a complete mole?
Scenario 9.
What is the risk of persistent GTD after a partial mole?
Scenario 10
What is the risk of requiring chemotherapy after a partial mole?
Scenario 11
What is the risk of requiring chemotherapy with hCG level > 20,000 i.u. one month after evacuation?
Scenario 12
What is the overall risk of requiring chemotherapy after molar pregnancy in the UK?
Scenario 13
What is the risk of requiring chemotherapy in the USA compared with the UK?
Scenario 14
What is the risk of molar pregnancy at age 15 compared to age 30?
Scenario 15
What is the risk of molar pregnancy at age 45 compared to age 30?