Thursday 18 May 2017

Tutorial 18th. May 2017

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18 May 2017.

1
How to prepare. What to read. Revision system. Study buddies. Statistics. Urogynae.
2
SBA. RCOG sample obstetric questions. There are also RCOG sample SBAs for gynaecology and sample EMQs. Go through all of them as they make for easy marks.
3
EMQ. Surrogacy.
4
Basic communication skills.
5
SBA. Placenta accreta, increta & percreta.
6
EMQ. Antenatal steroids.


1      How to prepare.
What to read. Revision system. Study buddies. Statistics. Urogynaecology.

2      SBA. RCOG sample obstetric
These can be downloaded from the RCOG website: https://www.rcog.org.uk/en/careers-training/mrcog-exams/part-2-mrcog/format/part-2-mrcog-sbas-single-best-answer-questions/part-2-mrcog-obstetric-sbas/. Some of the sample questions have come in the exam, so it is worth going through them.
3      Surrogacy.
I have put this in to illustrate the point that even seemingly super-specialised TOG articles can feature in the exam. There was a TOG article: “Surrogate pregnancy: ethical and medico-legal issues in modern obstetrics” by Celia Burrell and Hannah O'Connor, that I suspect that most people barely read. TOG. Volume 15, Issue 2, April 2013; Pages 113–9. The topic turned up as part of an OSCE a year or two later. There are a number of key legal points, which we will discuss.
Abbreviations.
ART:           assisted reproductive technology
CF:              commissioning father
CM:            commissioning mother
CPs:            commissioning parents
PO:             parental order
SM:             surrogate mother

Option List.
a)      CM
b)      CF
c)       CPs
d)      SM
e)      Chairman of the HFEA
f)        Senior judge at the Children and Family Court
g)       traditional surrogacy
h)      gestational surrogacy
i)        HFEA
j)        SSAEW
k)       RCOG Surrogacy Sub-Committee
l)        false
m)    true
n)      none of the above

Scenario 1
List the different types of surrogacy.
Scenario 2.
“Gestational” surrogacy has better “take-home-baby” rates than “traditional” surrogacy. True/False
Scenario 3.
There are approximately 1,000 surrogate pregnancies per annum in the UK. True/False
Scenario 4.
Which national body regulates surrogacy in England?
Scenario 5.
Privately-arranged surrogate pregnancies are illegal and those involved are liable to up to 2 years in prison. True/False
Scenario 6.
List the risks of surrogacy.
Scenario 7.
Obstetricians are legally obliged to take the CPs’ wishes into consideration in managing pregnancy complications or problems. True / False
Scenario 8.
The psychological outcomes of surrogacy are fully understood. True/False.
Scenario 9.
The psychological outcomes of surrogacy are more severe after traditional surrogacy. True/False
Scenario 10.
Who has the right to arrange TOP if the fetus is found to have a major congenital abnormality?
Scenario 11.
A SM decides at 10 weeks that she does not wish to be pregnant and arranges to have a TOP. The CPs. hear about this and object strongly. To whom should they apply to have the TOP blocked?
Scenario 12.
A woman has hysterectomy and BSO to deal with extensive endometriosis at the age of 30. She marries two years later and her sister offers to act as surrogate. She undergoes IVF and 4 embryos are created. One is transferred and a successful pregnancy ensues. The baby is adopted by the woman and her husband. The 3 remaining embryos were frozen. Four years later the woman falls out with her sister, but finds another surrogate and wishes to proceed with another pregnancy. The sister says she does not want her eggs to be used and that the frozen embryos should not be transferred. Does the sister have the legal right to block the use of the embryos? Yes / No.
Scenario 13.
A girl born from donor sperm reaches the age of 16 and wishes to know the identity of her genetic father. Does she have the right to this information?  Yes / No.
Scenario 14.
A girl born from donor sperm reaches the age of 18 and wins a place at Oxford University to read medicine. Does she have the legal right to get the donor to contribute to her fees? Yes / No.
Scenario 15.
A PO is active from the moment it is completed and signed by the relevant parties.  True/False
Scenario 16.
A SM can change her mind at any time and keep the child, even if the egg was not hers.  True/False
Scenario 17.
The CPs can change their mind, leaving the SM as the legal mother.  True/False
Scenario 18.
A SM’s husband is the legal father until adoption is completed or a PO comes into force. True/False
Scenario 19.
A lesbian couple in a stable, co-habiting relationship can be CPs and become the legal parents of the child of a SM. True/False
Scenario 20.
CPs are likely to get faster legal status as the legal parents through application for a PO rather than applying for adoption. True/False

4      Basic communication skills
Now is the time to start sorting out your communication skills so that the words you use in the part 3 are exactly those you already use in clinics. Even absolute basics like how to introduce yourself need to be thought about and practised.

5      SBA. Placenta accreta, increta & percreta
Placenta accreta increta & percreta
This topic has been chosen to remind you of the existence of UKOSS and the various Reports it has produced as they would make perfect EMQs or SBAs.
Abbreviations.
Creta:      term to describe accreta, increta or percreta.
PET:         pre-eclampsia
PIH:          pregnancy-induced hypertension
Question 1.
Lead-in
Choose the best option from the option list for the definition of placenta accreta.
Option List
A.       
Placenta which is difficult to remove, but can be separated digitally
B.       
Placental villi  invade the decidua, but not the myometrium
C.       
Placental villi  invade the decidua and myometrium but not the serosa
D.       
Placental villi  invade the decidua, myometrium and serosa
E.        
Placental villi  invade adjacent organs, e.g. the bladder
Question 2.
Lead-in
Choose the best option from the option list for the definition of placenta increta.
Option List
A.       
Placenta is difficult to remove, but can be separated digitally
B.       
Placental villi  invade the decidua, but not the myometrium
C.       
Placental villi  invade the decidua and myometrium but not the serosa
D.       
Placental villi  invade the decidua, myometrium and serosa
E.        
Placental villi  invade adjacent organs, e.g. the bladder
Question 3.
Lead-in
Choose the best option from the option list for the definition of placenta percreta.
Option List

A.       
Placenta is difficult to remove, but can be separated digitally
B.       
Placental villi  invade the decidua, but not the myometrium
C.       
Placental villi  invade the decidua and myometrium but not the serosa
D.       
Placental villi  invade the decidua, myometrium and serosa
E.        
Placental villi  invade adjacent organs, e.g. the bladder
Question 4.
Lead-in
What is the approximate incidence of placenta creta in the UK?
Option List

A.       
1-2 per   1,000 deliveries
B.       
1-2 per   1,000 maternities
C.       
1-2 per   5,000 deliveries
D.       
1-2 per   5,000 maternities
E.        
1-2 per 10,000 deliveries
F.        
1-2 per 10,000 maternities
Question 5.
You need to be able to define “maternity” and know why it is important.
Lead-in
What is a “maternity”?
Option List
A.       
Any pregnancy, including ectopic pregnancy
B.       
Any pregnancy, excluding ectopic pregnancy
C.       
Any pregnancy resulting in a live birth
D.       
Any pregnancy resulting in live birth or stillbirth
E.        
Any pregnancy ending from 24 completed weeks plus any pregnancy resulting in a live birth.
Question 6.
Lead-in
Why is the term “maternity” important.
Option List
A.       
We should take best possible care of our pregnant patients
B.       
It is used as the denominator in calculations of the maternal mortality rate
C.       
It is used as the numerator in calculations of the maternal mortality rate
D.       
It is used as the denominator in calculations of the maternal mortality ratio
E.        
It is used as the numerator in calculations of the maternal mortality ratio
Question 7.
This question relates to risk factors for placenta accreta
Lead-in
Match each of the risk factors  listed below with an adjusted odds ratio from the Option List. Each option can be used once, more than once or not at all.
Note that some of the adjusted odds ratios show a reduced risk.
Risk factors and adjusted odds ratio.
Risk factor
Adjusted odds ratio
BMI > 30

Cigarette smoking in pregnancy

Ethnic group non-white

IVF pregnancy

Maternal age > 35

Parity ≥ 2

PIH or PET

Placenta previa diagnosed pre-delivery

Previous Caesarean section > 1

Previous Caesarean section x 1

Previous uterine surgery – not C. section














Option List
Adjusted odds ratio
0.53
0.57
0.66
0.9
1.0
2.0
3.06
3.4
3.48
10
14
16.31
32.13
65.02
102
Question 8.
Lead-in
This question relates to estimated incidence of placenta creta for various risk factors.
Match the risk factors with the estimated incidence in the option list. Each option can be used once, more than once or not at all.
Risk factors and estimated incidence per 10,000 maternities.
Risk factor
Estimated incidence
No previous C section

≥ 1 C section

Placenta previa not diagnosed pre-delivery

Placenta previa diagnosed pre-delivery

Previous C section but placenta previa not diagnosed pre-delivery

Previous C section + placenta previa diagnosed pre-delivery











Option List
0.3
0.6
1
3
5
9
108
577
1,000

6      EMQ. Antenatal steroids
Lead-in.
The following scenarios relate to antenatal steroid use and the neonate.
Pick one option from the option list.
Each option can be used once, more than once or not at all.
Abbreviations.
ANS:      antenatal steroids.
FGR:      fetal growth restriction.
GTG:     Green-Top Guideline No 7 from the RCOG. “Antenatal Corticosteroids to Reduce Neonatal Morbidity and Mortality.”
RDS:      respiratory distress syndrome. In ancient times known as “hyaline membrane disease”. Now better known as “surfactant-deficient lung disease of the new-born”.
Option list.
There is no option list.
I want you to come up with your answers.
Scenario 1.
What are the benefits to the neonate of appropriate administration of antenatal steroids?
Scenario 2.
At what gestations should antenatal steroids be offered to women with singleton pregnancies who are at risk of premature labour?
Scenario 3.
At what gestations should antenatal steroids be offered to women with multiple pregnancies who are at risk of premature labour?
Scenario 4.
What advice is contained in the GTG in relation to very early gestations, threatened premature labour and the use of antenatal steroids.
Scenario 5.
What advice is contained in the GTG in relation to antenatal steroids and Caesarean section?
Scenario 6.
What advice is given in the GTG about ANS in relation to the fetus with FGR at risk of premature delivery?
Scenario 7
What advice is given in the GTG in relation to ANS for women with IDDM?
Scenario 8
What advice is in the GTG in relation to adverse effects of ANS on the fetus?
Scenario 9
What advice is in the GTG in relation to short-term maternal adverse effects?
Scenario 10
What contraindications to ANS are cited in the GTG?
Scenario 11
What is the recommended drug regime for ANS administration?
Scenario 12.
What is the time-scale for maximum effect of ANS in reducing RDS?
Scenario 13.
When should repeat courses of ANS be given?
Scenario 14.
When may antenatal steroids be beneficial to the fetus apart from accelerating lung maturation?



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