Tutorial 5th. January 2017

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5 January 2017.

55	EMQ. Menopause. NG23. Definition & diagnosis
56	EMQ. Menopause. NG23. Management
57	EMQ. Folic acid & pregnancy
58	SBA. CAESAR trial
59	SBA. Flu and pregnancy

55.         Menopause NG23. Diagnosis & definitions.

Abbreviations.

AFC:      antral follicle count.

AMH:    anti-Müllerian hormone.

POF:      premature ovarian failure.

POI:       premature ovarian insufficiency.

Question 1.

Which adjective did NICE use in relation to ideal care in recommendation 1.1.1 of NG23?

Option List

A.	best
B.	holistic
C.	individualised
D.	personalised
E.	privatised

Question 2.

What is the average age at the menopause?

Option List

A.	49 years
B.	50 years
C.	51 years
D.	52 years
E.	53 years

Question 3.

What age limit is used for the diagnosis of premature ovarian insufficiency?

Option List

A.	30 years
B.	35 years
C.	37 years
D.	40 years
E.	45 years

Question 4.

What is the approximate incidence of premature ovarian insufficiency?

Option List

A.	0.1%
B.	0.5%
C.	1%
D.	2%
E.	5%

Question 5.

What is the definition of the perimenopause?

Question 6.

What is the definition of the postmenopause?

Question 7.

What is the definition of premature ovarian insufficiency?

Question 8.

A healthy physics teacher of 35 is diagnosed as menopausal. There is no obvious explanation. Which of the following conditions could be the undiagnosed hereditary cause?

Option List

A.	Cystic fibrosis carrier status
B.	Elliptocytosis
C.	Fragile X carrier status
D.	Galactosaemia
E.	Polycythaemia vera

Question 9.

A healthy woman of 52 presents with amenorrhoea for 15 months and vasomotor symptoms. She is not taking any drugs. What tests should be done to confirm the diagnosis of the menopause.

Option List.

A.	FSH
B.	FSH & LH
C.	FSH & oestradiol
D.	AMH
E.	None of the above

Question 10.

A healthy woman of 46 presents with vasomotor symptoms and irregular periods. She is not taking any drugs. What tests should be done to confirm the diagnosis of the menopause?

Option List.

A.	FSH
B.	FSH & LH
C.	FSH & oestradiol
D.	AMH
E.	None of the above

Question 11.

Which tests does NICE say should not be used to diagnose the menopause and perimenopause in women > 45 years?

List of possible investigations.

A.	AFCA
B.	MH
C.	CT scan of pituitary fossa
D.	inhibin A
E.	inhibin B
F.	oestradiol
G.	ovarian volume
H.	prolactin
I.	thyroid function tests

Question 12.

What does NICE recommend with regard to the use of FSH in relation to diagnosis of the menopause?

Question 13.

What does NICE recommend with regard to the use of FSH in relation to diagnosis of the perimenopause?

Question 14.

What does NICE say about the cost of FSH assay?

Question 15.

Which of the following statements, if any, are true in relation to the advice from NICE about the diagnosis of the menopause?

Option List

A	diagnose without lab tests in healthy women > 45 years with menopausal symptoms
B	diagnose without lab tests in healthy women > 50 years with menopausal symptoms
C	diagnose without lab tests in women > 50 years with amenorrhoea > 6/12 and not taking hormones
D	diagnose without lab tests in women > 55 years with amenorrhoea > 6/12 and not taking hormones
E	diagnose on symptoms without lab tests in women > 45 years who have had hysterectomy and are not taking hormones
F	none of the above

Question 16.

Which of the following statements is true in relation to the advice from NICE about the diagnosis of the perimenopause?

Option List

A	diagnose without lab tests in healthy women > 45 years with menopausal symptoms
B	diagnose without lab tests in healthy women > 50 years with menopausal symptoms
C	diagnose without lab tests in women > 50 years with amenorrhoea > 6/12 and not taking hormones
D	diagnose without lab tests in women > 55 years with amenorrhoea > 6/12 and not taking hormones
E	diagnose on symptoms without lab tests in women > 45 years who have had hysterectomy and are not taking hormones
F	none of the above

Question 17.

What does NICE recommend with regard to the use of oestradiol assay in relation to diagnosis of the menopause and perimenopause?

Question 18.

What does NICE recommend in relation to the diagnosis of POI?

Question 19.

NICE uses the term “urogenital atrophy” for the changes that may accompany the menopause. There is now a preferred term – what is it?

Question 20.

NICE describes 3 ‘challenges’, parts of NG23 that could have ‘a big impact on practice’ but be ‘challenging to implement’.

Which, if any, of the following are included in the ‘challenges’.

Possible ‘challenges’

A	increasing the uptake of HRT or non-hormonal alternatives to ↓ the burdens caused by osteoporosis in an ageing population
B	increasing the uptake of HRT to ↓ the burdens caused by Alzheimer’s disease in an ageing population
C	reducing unnecessary use of FSH tests in the diagnosis of the menopause
D	providing better information about the long-term benefits and risks of HRT
E	providing adequate specialist services for an ageing population
F	encouraging GPs to discuss the benefits and risks of HRT with all of their menopausal patients

Option List

1	A + B + C + D + E + F
2	A + B + C + D + E
3	B + D + E + F
4	C + D + E
5	C + D  + F

56.         Menopause NG23. Management.

This is a follow-on from the SBA on “Menopause. NG23. Diagnosis & definitions”.

Question 1.

What information should be given to menopausal women considering treatment?

Option List

There is none: this could be an OSCE station with no option list and you need to have the answers in your large brain.

Question 2.

How does NICE define “short-term” in relation to risks and benefits?

Option List

F.	≤ 6 months
G.	≤ 1 year
H.	≤ 18 months
I.	≤ 2 years
J.	≤ 5 years

Answer. E. 5 years.

Question 3.

What does NG 23 say about how information should be provided?

Option List

F.	orally
G.	orally and written
H.	orally, written and using intranet
I.	orally, written and using internet
J.	in different ways

Question 4.

Lead-in. What symptoms does NG23 include as associated with the menopause?

List of symptoms.

A	joint and muscle pain
B	menstrual cycle changes
C	mood changes
D	vaginal dryness
E	vasomotor symptoms

Question 5.

What information does NG23 say should be given to women about the available types of treatment for menopausal symptoms?

Question 6.

Which of the following are recommended in relation to review / follow-up for short-term symptoms.

A	review each treatment at 3/12 for efficacy / tolerability
B	review annually once established on treatment
C	review every 2 years once established on treatment
D	use NICE chart for documenting efficacy
E	none of the above

Question 7.

Which of the following should be advised in relation to starting / stopping HRT

A	unscheduled vaginal bleeding is common
B	unscheduled vaginal bleeding should be reported immediately
C	HRT should be stopped until unscheduled vaginal bleeding is investigated
D	HRT is best stopped in a regime of gradual reduction
E	none of the above

Question 8.

A woman with a high risk of breast cancer due to being a carrier of a BRCA1 mutation wishes to discuss HRT. Which of the following is true.

Option List

F.	oestrogen-only HRT is safe for her to use in relation to breast cancer risk
G.	HRT is contraindicated and should not be used
H.	paroxetine should not be used when taking tamoxifen
I.	fluoxetine is safe to use when taking tamoxifen
J.	none of the above

Question 9.

Lead-in. A woman has a diagnosis of POI at the age of 35. She has no risk factors for oestrogen therapy and there is no family history of note. She wishes to discuss HRT. Which of the following are true and worthy of discussion.

Option List.

F.	HRT or the COC protect against osteoporosis if taken to the average age at the menopause
G.	HRT is less likely to be linked to the development of hypertension
H.	combined HRT and the COC are linked to an increased risk of breast cancer, but the increase is small
I.	contraception is not needed when she has gone 12 months from the diagnosis of POI
J.	none of the above

Question 10.

Which of the following are true of transdermal oestrogen.

Option List.

F.	transdermal HRT at standard doses ↑ the risk of diabetes, but < oral HRT
G.	transdermal HRT at standard doses ↑ the risk of stroke, but < oral HRT
H.	transdermal HRT at standard doses does not ↑ the risk of VTE
I.	VTE risk is less with transdermal HRT than oral
J.	none of the above

57.         Folic acid & pregnancy.

Lead-in.

There is no option list. You have to decide your answers.

Scenario 1.                

What is the incidence of NTD in the UK?

Scenario 2.                

What is the risk of an affected sibling for the woman who becomes pregnant after having a baby with NTD?

Scenario 3.                

Which foods contain significant amounts of folic acid?

Scenario 4.                

What percentage of folic acid is destroyed by cooking / food storage?

How many people in the UK are estimated to have a folate-deficient diet?

Scenario 5.                

What is the significance of the MTHFR (Methylenetetrahydrofolate reductase gene)?

Scenario 6.                

What is the significance of the Meckel-Gruber syndrome to this issue?

Scenario 7.                

By what gestation has the neural tube closed?

Scenario 8.                

What proportion of pregnant women have taken folic acid preconceptually?

Scenario 9.                

What dose and duration of folic acid is advised for routine periconceptual use?

Scenario 10.            

List the women to whom a higher dose should be offered.

Scenario 11.            

How effective is periconceptual folic acid consumption in reducing NTD risk in the low-risk population?

Scenario 12.            

How effective is periconceptual folic acid consumption in reducing NTD risk in women who have had an affected baby?

Scenario 13.            

What is the risk of NTD recurrence for a woman who has had two affected babies?

Scenario 14.            

What is the risk of NTD in Ireland?

Scenario 15.            

Scenario 16.            

What effect does periconceptual folic acid have on the risk of stillbirth?

Scenario 17.            

What effect does periconceptual folic acid have on the risk of autistic spectrum disorder?

Scenario 18.            

What effect does periconceptual folic acid have on maternal haemoglobin levels?

Scenario 19.            

What recommendations have been made by the RCOG to improve folic acid levels in pregnancy?

Scenario 20.            

Which names are of importance in the history of folic acid and NTD?

Scenario 21.            

What neurological condition has been thought potentially problematic with folic acid supplementation?

58.         The “CAESAR” trial

Abbreviations.

ECV:      external cephalic version

Suggested reading.

The CAESAR study collaborative group: “Caesarean section surgical techniques: a randomised, factorial trial (CAESAR).” BJOG 2010;117:1366–1376.

Question 1.

Lead-in

What was the CAESAR trial?

Which, if any, of the following statements are true?

Statements

A	a prospective, cohort study
B	a randomised, controlled trial
C	a comparison of selected techniques used during C section
D	a study of the risks of C section on maternal request without medical grounds
E	a study of the outcomes of C section performed after failed instrumental delivery

Option List

1	A + C
2	A + D
3	B + C
4	B + D
5	B + E

Question 2.

Lead-in

Where did the questions addressed by the trial come from?

Option list

A	the RCOG council
B	the RCOG exam committee
C	a survey of UK obstetricians asking what questions they would like to have answered
D	Dr. Johnstone, Consultant Obstetrician, Falkirk
E	National Childbirth Trust

Question 3.

Lead-in

The questionnaire also asked about the issues that the respondents would like to see addressed in a research programme. What issues were include in the CAESER trial?

Statements

A	outcome of C. section depending on aqueous versus alcohol-based skin preparation
B	outcomes of cord traction versus manual removal of the placenta
C	outcomes of digital versus ‘swab on a holder’ exploration of the uterine cavity to exclude RPOC
D	outcomes of Joel-Cohen compared with Pfannenstiel incision
E	outcome of elective C. section at 38 versus 39 weeks
F	outcome of elective C. section with staff wearing masks versus not wearing masks
G	outcome of prophylactic antibiotics versus no prophylactic antibiotics
H	outcome of pre-op vaginal antiseptic “painting”
I	outcome of blunt v. sharp opening of the lower segment
J	outcomes of manual versus forceps delivery of the fetal head in cephalic presentations
K	outcome of single v double closure of the lower segment
L	outcome of closure v non-closure of parietal & pelvic peritoneum
M	outcome of liberal v restricted use of pelvic drains
N	outcome of glue v subcuticular suturing of the skin
O	none of the above

Option List

1	A + B + C + D + E + F + G + H + I + J + K+ L + M + N + O
2	D + F + G + H + K+ L
3	G + H + K+ L + M
4	K + M
5	O

Question 4.

Lead-in

Which of the following statements is true of the definition of the 1ry. outcome?

Option list

A	use of antibiotics for maternal infectious morbidity during the hospital stay
B	use of antibiotics for maternal infectious morbidity during the 1st. six weeks
C	duration of postnatal hospital stay
D	abdominal and pelvic pain as measured on an analogue scale at 6 weeks
E	none of the above.

Question 5.

Lead-in

Which, if any, of the following describe the 2ry. outcomes?

Statements

A	additional treatments to the abdominal wound
B	haematoma formation
C	pain
D	breast feeding at discharge
E	breast feeding at 6 weeks
F	unexpected maternal morbidity
G	postnatal depression at 6 weeks
H	puerperal psychosis

Option List

1	A + C
2	A + D
3	B + C
4	B + D
5	B + E
6	none of the above

Question 6.

Lead-in

Which if any of the following statements are true of the findings of the study?

Statements

A	there were no significant differences for any outcome
B	there was more endometritis after non-closure of the pelvic peritoneum
C	there was more 2ry. bleeding after interrupted-suture closure of the lower segment
D	there was more evidence of pelvic infection with liberal use of pelvic drains
E	none of the above.

59.         Flu and pregnancy

Question 1.

Lead-in

What did MBRRACE say about flu & pregnancy in its first report in 2014?

Option List

Pick the best option from the following list.

F.	1 in 11 women died from flu
G.	1 in 11 women died from flu and flu vaccination could have prevented ½ of the deaths
H.	1 in 21 women died from flu
I.	1 in 21 women died from flu and flu vaccination could have prevented ½ of the deaths
J.	1 in 51 women died from flu
K.	1 in 51 women died from flu and flu vaccination could have prevented ½ of the deaths

Question 2.

Lead-in

How many types of flu virus are recognised?

Pick the best option from the following list.

Option List

K.	3
L.	5
M.	10
N.	15
O.	>100

Question 3.

Lead-in

Why can’t we have a universal flu vaccine?

Pick the statements from the following list that are true.

List of statements.

A.	The main surface antigens are haemagglutinin and neuraminidase
B.	The main surface antigens are haemolysin and neuroxidase
C.	The main surface antigens frequently
D.	The main core antigens change frequently, rendering existing vaccines impotent
E.	The big drug companies avoid making a universal vaccine for financial reasons.

Option List

1.	A + C + D + E
2.	A + C
3.	A + D + E
4.	B + C
5.	B + D + E

Question 4.

Lead-in

When is flu’ most often a problem in the UK?

Pick the best option from the following list.

Option List

A.	Spring
B.	Summer
C.	Autumn
D.	Winter
E.	None of the above.

Question 5.

Lead-in

How is flu spread?

Pick the best option from the following list.

Option List

A.	via aerosol or droplets from respiratory tract of an infected person
B.	via aerosol or droplets from respiratory tract or direct contact with respiratory secretions  of an infected person
C.	from getting drenched in cold winter showers
D.	from thinking lascivious thoughts
E.	from toilet seats

Question 6.

Lead-in

What is the incubation period for flu?

Pick the best option from the following list.

Option List

A.	1 – 3 days
B.	1 – 7 days
C.	5 – 10 days
D.	up to 2 weeks
E.	up to 3 weeks

Question 7.

Lead-in

Who decides which viruses will be used in the vaccine for seasonal flu?

Pick the best option from the following list.

Option List

	DOH
	JCVI
	the Prime Minister
	the vaccine manufacturers
	WHO

Question 8.

Lead-in

How long has flu vaccination been recommended in the UK?

Pick the best option from the following list.

Option List

A.	since the 1950s
B.	since the 1960s
C.	since the 1970s
D.	since the 1980s
E.	since the 1990s

Question 9.

Lead-in

What is the recommendation about when the vaccine should be given?

Pick the best option from the following list.

Option List

A.	May - July
B.	June - August
C.	July - September
D.	August - October
E.	September - November

Question 10.

Lead-in

What advice is given about vaccination in pregnancy?

Pick the best option from the following list.

Option List

A.	flu vaccine is potentially teratogenic and should be avoided before 16 weeks
B.	the vaccine contains an attenuated virus with no evidence of risk in pregnancy
C.	the vaccine recommended for pregnancy has no live viral material and all pregnant women are encouraged to have the seasonal vaccine
D.	flu vaccine contains an attenuated virus with minimal risk, but the anti-viral drug Tamiflu is given with the vaccine to eliminate any risk of harm

Question 11.

Lead-in

What is the H1N1 virus?

Pick the best option from the following list.

Option List

A.	The avian virus which causes outbreaks of “bird flu”
B.	The virus associated with “swine” flu, which caused a pandemic in 2009
C.	The virus associate with MERS, currently causing deaths particularly in Saudi Arabia
D.	The virus associated with simian flu
E.	The virus associated with the pandemic of 1915.

Question 12.

Lead-in

What advice should be given to pregnant women about protection against the H1N1 virus?

Pick the best option from the following list.

Option List

F.	to have vaccination against H1N1 in addition to the seasonal vaccine
G.	to have vaccination against H1N1 in preference to the seasonal vaccine
H.	to await evidence of epidemic H1N1 flu and then have vaccination against H1N1
I.	to have the seasonal vaccine as it gives good protection against H1N1
J.	not to have any flu vaccination, but to take antiviral drugs if symptoms of flu occur

Question 13.

Lead-in

Pick the best option from the following list.

Which of the following conditions have been linked to flu in pregnancy?

Conditions.

A.	­ risk of flu complications for the mother
B.	­ risk of low birthweight
C.	­ risk of maternal death
D.	­ risk of perinatal death
E.	­ risk of  prematurity

Option List

1	A + C+ D + E
2	A + B + C+ D
3	A + C + D
4	A + C+ D + E
5	A + B + C+ D + E

Question 14.

Lead-in

What is the estimated uptake of flu vaccination by pregnant women in the UK?

Pick the best option from the following list.

Option List

A.	20-30%
B.	30-40%
C.	40-50%
D.	50-60%
E.	> 60%

Question 15.

Lead-in

How many maternal deaths were reported by MBRRACE for the years 2012 - 2013?

Pick the best option from the following list.

Option List

A.	0
B.	5
C.	10
D.	15
E.	20

Question 16.

Lead-in

With regard to the probable explanation for the numbers of maternal deaths from ‘flu in 2012 and 2013, which of the following statements is true?

Option List

A.	the numbers reflected increased prevalence of ‘flu
B.	the numbers reflected reduced prevalence of ‘flu
C.	the numbers reflected improved uptake of ‘flu vaccine in pregnancy
D.	the numbers reflected the introduction of Tamiflu for pregnant women with ‘flu
E.	none of the above