Thursday 2 February 2017

Tutorial 2nd. February 2017

2 February 2017.

67
EMQ. Puerperal mental illness
68
SBA. WHO criteria for a screening programme
69
EMQ. Kallmann’s syndrome
70
SBA. Recurrent miscarriage.

Question 67.     EMQ. Puerperal mental illness.
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.
If I had put all the answers into the option list it would have been enormous. So there are quite a few where you need to decide what your answer would be. Opting for “none of the above” is not exercising your brain – make sure you come up with an answer.
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 for postpartum psychiatric disorders?
Scenario 4
What clinical classification would you use in a viva?
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?


Question 68.     WHO criteria for a screening programme.
Question 1.
Lead-in
List as many as you can of the WHO criteria.
Option List
There is none. But there are 10 criteria – just trying to be helpful!
Question 2.
Lead-in
Which, if any, of the following statements are true in relation to the WHO criteria for a screening test?
Option List
A
screening should be for an important health problem
B
there should be an accepted treatment
C
facilities for diagnosis and treatment should exist
D
there should be an identifiable latent or early stage of the condition
E
there should be a suitable screening test
Question 3.
Lead-in
Which, if any, of the following statements are true in relation to the WHO criteria for a screening test?
Option List
A.       
the test should acceptable to the population to be screened
B.       
the natural history of the condition should be fully understood, particularly the factors causing progression from latent to established disease
C.       
there should be agreement on whom to treat
D.       
the financial cost of the screening programme and any consequent treatments should be reasonable in relation to the available budget for medical care
E.        
case-finding should be continuous and not a “one-off” exercise
Question 4.
Lead-in
Who wrote the original paper on which the WHO criteria are based?
Option List
A.       
Felix & Juggler
B.       
Harriman & Jones
C.       
Stevenson & Jugular
D.       
Waterston & Juggernaut
E.        
Wilson & Jugner

Question 69.     Kallmann’s syndrome.
Abbreviations.
Ks:         Kallmann’s syndrome
Scenario 1.                
Which of the following might be included in descriptions of Kallmann’s syndrome?
Option list.
A
hypogonadotrophic hypogonadism
B
hypogonadotrophic hypogonadism + anosmia
C
hypogonadotrophic hypogonadism + anosmia + colour-blindness.
D
hypogonadotrophic hypogonadism due to uterine agenesis
Scenario 2.                
Lead in.
Which, if any, of the following are features of the Kallmann phenotype?
A
absent or minimal breast development
B
aortic stenosis
C
blue eyes
D
blue hair
E
hot flushes
F
short stature
G
tall stature
H
vaginal agenesis
I
none of the above
Scenario 3.                
How common is Kallmann’s syndrome and what is the female: male ratio?
A
1 in 1,000 and F:M ratio 1:1
B
1 in 5,000 and F:M ratio 1:1
C
1 in 10,000 and F:M ratio 1:4
D
1 in 50,000 and F:M ratio 1:4
E
1 in 100,000 and F:M ratio 1:8
F
1 in 250,000 and F:M ration 1:10
Scenario 4.                
What is the most common mode of inheritance of Ks?
Option list.
A
hypogonadotrophic hypogonadism
B
hypogonadotrophic hypogonadism + anosmia
C
hypogonadotrophic hypogonadism due to uterine agenesis
D
autosomal dominant
E
autosomal recessive
F
X-linked recessive
G
new mutation of the ANOS1 gene
H
the most common mode of inheritance is not known
Scenario 5.                
How is Kallmann’s syndrome diagnosed?
A
abdominal and pelvic ultrasound scan
B
cell-free fetal DNA
C
chromosome analysis
D
CT scan of hypothalamus / pituitary
E
MR scan of hypothalamus / pituitary
F
none of the above.
Scenario 6.                
How is Kallmann’s syndrome treated initially?
Which of the following statements are true?
Option list.
A
GnRH analogue depot
B
pulsatile GnRH therapy
C
combined oral contraceptive
D
counselling & education re gender re-assignment
E
depot progestogen
F
none of the above



Scenario 7.                
A woman was diagnosed with Kallmann’s syndrome at 16 and had successful initial treatment. She is now 25, married and wishes to have a pregnancy. She has had pre-pregnancy assessment and counselling. Which of the following can be considered?
A
GnRH analogue depot
B
induction of ovulation with clomiphene
C
gonadotrophin therapy
D
pulsatile GnRH therapy
E
none of the above

Question 70.     Recurrent Miscarriage.
This question and answer are derived from a question written by Selvambigai Raman.
Abbreviations.
EPAS:            early pregnancy assessment service.
EPU:              dedicated early pregnancy assessment unit.
GDG:             guideline development group.
GGT:              Gamma-glutamyl transferase.
GTD:              gestational trophoblastic disease.
NK:                natural killer.
PCOS:            polycystic ovary syndrome.
PIGD:            pre-implantation genetic diagnosis.
PIGS:             pre-implantation genetic screening.
RM:               recurrent miscarriage.
TORCH:         Toxoplasmosis, rubella, cytomegalovirus & herpes. (Other definitions include HIV, syphilis and other infections.) Fortunately, TORCH screening is out-of-date, exact definitions are not important, though I’d stick with the first if asked.
UA:                uterine anomaly.

Question 1.
Lead-in
In relation to miscarriage, which, if any, of the following statements are correct?
  1. the term “spontaneous miscarriage” is really stupid
  2. most miscarriages are genetic in causation.
  3. most women who miscarry do not get a diagnosis of causation
  4. the majority of women have significant levels of psychological distress after miscarriage.
  5. counselling is of significant benefit in reducing levels of psychological distress after miscarriage.
Option List
A.       
i + ii
B.       
i + ii + iii
C.       
i + ii + iii + iv
D.       
i + ii + iii + v
E.        
i + ii + iii + iv + v
Question 2.
Lead-in
Which of the following statements are true.
  1. miscarriage occurs in 11% of women with age 20-24 years
  2. miscarriage occurs in 25% of women with age 35-39 years
  3. miscarriage occurs in > 90% of mothers with age ≥ 45 years
  4. recurrent miscarriage affects about 1% of couples
  5. recurrent miscarriage affects about 5% of couples
Option List
A.       
i + ii
B.       
i + iii
C.       
i + ii + iv
D.       
i + iii + v
E.        
i + ii + iii + iv
Question 3.
Lead-in
What figure is usually given for the overall incidence of miscarriage?
Option List
A.       
< 10 %
B.       
10 - 20%
C.       
20 - 25%
D.       
25 – 30 %
E.        
>30%
Question 4.
Lead-in
A healthy, 26-year-old, woman attends the booking clinic at 6 weeks in her first pregnancy. A pregnancy test is +ve. Her best friend recently had an early miscarriage and she is concerned about her risk. What risk will you quote?
Option List
A.       
≤ 5%
B.       
5 – 10%
C.       
10 – 15%
D.       
15 – 20%
E.        
≥ 20%
Question 5.
Lead-in
The same healthy woman attends the ANC at 8 weeks for a dating scan. Before she has the scan she asks you what her risk is now. She has had no abnormal symptoms. What risk will you quote?
Option List
A.       
≤ 5%
B.       
5 – 10%
C.       
10 – 15%
D.       
15 – 20%
E.        
≥ 20%
Question 6.
Lead-in
The same healthy, nulliparous woman comes back to see you after the scan. The scan is normal and shows a viable fetus. She asks what her risk is now. What risk will you quote?
Option List
  1.  
≤ 5%
  1.  
5 – 10%
  1.  
10 – 15%
  1.  
15 – 20%
  1.  
≥ 20%
Question 7.
Lead-in
Pick the best option from the list below for the definition of RM.
Option List
  1.  
two or more miscarriages
B.
two or more miscarriages in healthy women
C.
three or more miscarriages
D.
three or more miscarriages in women with no children
E.
none of the above.
Question 8.
Lead-in
The following are possible causes of RM except for one. Pick the best option for the exception.
Option List
  1.  
increased maternal age
  1.  
maternal cigarette smoking
  1.  
maternal alcohol consumption
  1.  
exposure to anaesthetic gases
  1.  
exposure to emissions from video display terminals
 Question 9.
Lead-in
A woman presents to antenatal clinic for booking at 6 weeks. She has a history of 3 RMs with no explanation found after full investigation. What is her risk of miscarriage in this pregnancy?
Option List
A.       
≤ 10%
B.       
   20%
C.       
   25%
D.       
   50%
E.        
   75%
Question 10.
Lead-in
A 35-year-old woman with a history of 3 RMs presents to you for advice regarding the risk of miscarriage if she conceives. Pick the best option to describe her risk from the list below.
Option List
F.        
20%
G.       
30%
H.       
40%
I.         
50%
J.         
55%
Question 11.
Lead-in
The following statement relates to women with arcuate uteri.
There is evidence to suggest that women with arcuate uteri:
                i.     tend to miscarry more in first trimester
              ii.     tend to miscarry more in second trimester
            iii.     have no increased risk of miscarriage
            iv.     are at increased risk of cephalo-pelvic disproportion
              v.     are at increased risk of Caesarean section
Pick the best option from the list below.
Option List
A.       
i
B.       
i + v
C.       
ii + iv
D.       
ii + v
E.        
iii + v
Question 12.
Lead-in
With regards to EPUs, which of the following statements, if any, are true.
         i.            all women with pain + bleeding in early pregnancy can self-refer to an EPU
       ii.            all women with pain + bleeding in early pregnancy should be seen by a health professional before referral to an EPU
     iii.            women with a history of ectopic pregnancy, molar pregnancy or recurrent miscarriage should be able to self-refer to an EPU
     iv.            women with a history of puerperal psychosis should be able to self-refer to an EPU
Option List
A.       
i
B.       
ii
C.       
iii
D.       
iv
E.        
iii + iv
Question 13.
Lead-in
Which, if any, of the following investigations should be done for a couple with 1st trimester RM?
         i.            APS screen
       ii.            Fragile X syndrome screen
     iii.            HbA1c
     iv.            hysterosalpingogram
       v.            inherited thrombophilia screen
     vi.            karyotyping
    vii.            NK cells in peripheral blood
  viii.            thyroid function tests
     ix.            TORCH screen
Option List
A.       
i
B.       
i +  v
C.       
i + ii + v + vi + viii + ix
D.       
i + iii + iv + v + vi + vii + viii + ix
E.        
all of the above except vii
Question 14.
Lead-in
Which, if any of the following treatments should be offered to women with RM and evidence of APS?
Option List
         i.             
low-dose aspirin + clopidogrel
       ii.             
low-dose aspirin + LMWH
     iii.             
low-dose aspirin + LMWH + low-dose corticosteroids
     iv.             
low-dose aspirin + unfractionated heparin
       v.             
low-dose aspirin  + unfractionated heparin + low-dose corticosteroids
Question 15.
Lead-in
Which, if any, of the following treatments are of proven benefit in improving outcomes in unexplained RM?
         i.            cervical cerclage
       ii.            hCG
     iii.            leptin
     iv.            LH
       v.            metformin
     vi.            rectal or vaginal progesterone
    vii.            supportive therapy in a dedicated EPU
  viii.            PIGS
Option List
A.       
i + ii
B.       
i + vi + vii
C.       
ii + vi + vii + vii
D.       
 vii
E.        
none of the above
Question 16 .
Lead-in
With regard to the role of PIGS in the management of women with unexplained RM, which, if any, of the following statements are true.
         i.            PIGS is of proven benefit in unexplained RM
       ii.            PIGS is regulated by the HFEA
     iii.            PIGD and PIGS are different names for the same process
Option List
A.       
i
B.       
ii
C.       
i + ii
D.       
i + ii + iii
E.        
none of the above
Question 17.
Lead-in
Pick the most appropriate option from the list below about the risk of miscarriage in women with PCOS and a history of RM who conceive spontaneously.
Option List
F.        
increased serum LH levels predict an increased risk of miscarriage
G.       
Increased testosterone levels predict an increased risk of miscarriage
H.       
Decreased androgen levels predict an increased risk of miscarriage
I.         
Typical PCOS ovarian morphology predicts an increased risk of miscarriage
J.         
Hyperinsulinaemia predicts an increased risk of miscarriage




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