26 June 2017.
26
|
SBA. Progestogen-only implants
|
27
|
EMQ. Anatomy of fetal skull and maternal
pelvis
|
28
|
EMQ. Early pregnancy: diagnoses to exclude
|
29
|
EMQ. Early pregnancy: management.
|
26. EMQ.
Progestogen-only implants.
Progestogen-only
Implants.
Abbreviations.
ENG: etonorgestrel
HFW: hormone-free week
LNG: levonorgestrel
Question 1.
Lead-in
Pick the best option from the list below in relation to the hormone in
Nexplanon.
Option List
|
|
68 mg. ENG
|
|
|
100
mg. ENG
|
|
|
100
mg. LNG
|
|
|
150
mg. LNG
|
|
|
50
mg. ENG + 100 mg. LVG
|
Question 2.
Lead-in
How
does Nexplanon act as a contraceptive?
i.
mainly by inducing anovulation
ii.
mainly by altering cervical mucus to the
detriment of sperm transport
iii.
mainly by thinning the endometrium, preventing
implantation
iv.
mainly by inducing loss of libido
Choose
the best option from the list below.
Option List
|
|
I
|
|
|
I +
II
|
|
|
I +
III
|
|
|
II
+ III
|
|
|
III
+ IV
|
Question 3.
Lead-in
What is the age range, if any, for which Nexplanon is licensed in the
UK?
Option List
|
|
15 – 50 years
|
|
|
18
– 40 years
|
|
|
18
– 45 years
|
|
|
20
– 50 years
|
|
|
None
of the above.
|
Question 4.
Lead-in
A woman
who is not in the licensed age range requests a Nexplanon. How should the
advising doctor proceed?
Option List
|
|
Advise her about alternative licensed contraceptive methods, but
decline to insert Nexplanon
|
|
|
Advise
her about alternative licensed contraceptive methods and insert Nexplanon
|
|
|
Fit
her with a LNGIUS
|
|
|
Refer
her to a colleague who fits anyone who asks with a Nexplanon
|
|
|
None
of the above
|
Question 5.
Lead-in
Which, if any, of the following statements best describes the pregnancy
rate for women using Nexplanon are true?
Option List
|
|
The pregnancy rate is < 1 per 1,000 women during 3 years of use
|
|
|
The pregnancy rate is < 5 per 1,000 women during 3 years of use
|
|
|
The pregnancy rate is < 10
per 1,000 women during 3 years of use
|
|
|
The
pregnancy rate is 10-20 per 1,000 women during 3 years of use
|
|
|
None
of the above
|
Question 6.
Lead-in
Which, if any, other implants are licensed in the UK?
Option List
|
|
Implanon
|
|
|
Norplant
|
|
|
Norplant-2
|
|
|
Jadelle
|
|
|
None
of the above
|
Question 7.
Lead-in
What are the main differences between Nexplanon and Implanon?
Pick
the most suitable answer from the list below.
Option List
|
|
The dosage was increased from 60 to 68 mg. etonorgestrel
|
|
|
The
dosage was increased from 150 – 175 mg. levonorgestrel
|
|
|
Barium
sulphate was added to Nexplanon to make it radio-opaque
|
|
|
The
number of rods was reduced to 2
|
|
|
None
of the above
|
Question 8.
Lead-in
What problems is the new applicator designed to minimise?
I.
non-insertion
II.
deep insertion
III.
difficulty with one-handed insertion
IV.
difficulty with left-handed insertion
V.
difficulty with insertion in very thin women.
Option List
|
|
I + II + III + IV
|
|
|
I + II + III + IV + V
|
|
|
II + III
|
|
|
II + III + IV
|
|
|
II + III + IV + V
|
Question 9.
Lead-in
How long is Nexplanon licensed for?
Option List
|
|
1 year
|
|
|
2 years
|
|
|
3
years
|
|
|
5
years
|
|
|
10
years
|
Question 10.
Lead-in
What does NICE recommend that patients be told about bleeding patterns
with Nexplanon?
I.
menstrual bleeding may cease
II.
menstrual bleeding may become prolonged
III.
bleeding may become more frequent
IV.
menstrual bleeding may become less frequent
V.
intermenstrual bleeding can be a problem in the
first 6 months
Option List
I + II + III
|
|
I + II + III + IV
|
|
II + III + IV + V
|
|
I + III + IV
|
|
I + III + IV + V
|
Question 11.
Lead-in
What
information should women be given about the effect of Nexplanon on pain?
Option List
|
|
Dysmenorrhoea may increase
|
|
|
Dysmenorrhoea
may decrease
|
|
|
Mittelschmerz is likely to cease
|
|
|
Pain
due to endometriosis is likely to decrease
|
|
|
Dyspareunia
is likely to be alleviated
|
Question 12.
Lead-in
A
25-year old nulliparous woman has been found to have a few spots of
endometriosis in the pouch of Douglas at laparoscopy for pelvic pain. She
wishes to avoid pregnancy for 5 years but then wishes to have two children. She
has read an article suggesting that a progesterone-only implant provides high
levels of contraceptive efficacy and good results in suppressing endometriosis.
What advice will you give?
Option List
|
|
Recommend a low-dose COC and tricycling as the best means of
suppressing endometriosis plus providing effective contraception
|
|
|
Recommend a low-dose COC taken continuously as the best means of
suppressing endometriosis plus providing effective contraception
|
|
|
Recommend
Nexplanon as the best means of suppressing endometriosis plus providing
effective contraception
|
|
|
Recommend
Depot-Provera as the best means of suppressing endometriosis plus providing
effective contraception
|
|
|
None
of the above
|
Question 13.
Lead-in
When
can a Nexplanon be inserted with no need for additional contraception in a woman with regular menstrual cycles and
no contraindication to its use?
Option List
|
|
Up to and including day 3 of menstruation
|
|
|
Up
to and including day 5 of menstruation
|
|
|
Up
to and including day 7 of menstruation
|
|
|
Never
|
|
|
None
of the above
|
Question 14.
Lead-in
A
healthy 25 year-old-woman is recovering well from a normal delivery. She is not
breastfeeding and wishes to start Nexplanon.
Option List
Pick the best statement from the list below.
|
|
No additional contraception is needed if Nexplanon is inserted by day
7
|
|
|
No
additional contraception is needed if Nexplanon is inserted by day 14
|
|
|
No
additional contraception is needed if Nexplanon is inserted by day 21
|
|
|
No
additional contraception is needed if Nexplanon is inserted by day 28
|
|
|
No
additional contraception is needed if Nexplanon is inserted by day 42
|
Question 15.
Lead-in
A
healthy 20-year-old woman wishes to switch from a COC to Nexplanon. What rules
apply to the need for additional contraception?
I
|
If
insertion takes place on day 1 of the HFW, no additional contraception is
needed.
|
II
|
If
insertion takes place on day 5 of the HFW, additional contraception is needed
for 7 days.
|
III
|
If
insertion takes place in week 2 after the HFW, no additional contraception is
needed.
|
IV
|
If
insertion takes place in week 3 after the HFW, no additional contraception is
needed.
|
Option List
A
|
I
|
B
|
I +
II
|
C
|
I +
II + III
|
D
|
II
+ III + IV
|
E
|
I +
II + III + IV
|
Question 16.
Lead-in
I
|
Women
switching from a POP to Nexplanon should be advised that additional contraception
is required for 7 days.
|
II
|
Women
switching from a POP to Nexplanon should be advised that additional
contraception is not required.
|
III
|
Women
switching from a LNGIUS to Nexplanon should be advised that additional
contraception is required for 7 days.
|
IV
|
Women
switching from a LNGIUS to Nexplanon, should be advised that additional
contraception is not required.
|
Option List
A
|
I + III
|
B
|
I +
IV
|
C
|
II
+ III
|
D
|
II
+ IV
|
E
|
none
of the above
|
27. EMQ. Anatomy of fetal skull and maternal pelvis.
This is a new answer. Please let me know if you find any
errors, typos or bits that are not clear.
Scenario 1.
How many bones make up the
vault of the skull?
Option list.
A.
|
3
|
B.
|
5
|
C.
|
6
|
D.
|
7
|
E.
|
8
|
Scenario 2.
What is the origin of the word
“bregma”?
Option list.
A.
|
the Greek word meaning “arrow”
|
B.
|
the Greek word meaning “front of the head”
|
C.
|
the Greek word meaning “top of the head”
|
D.
|
the Greek word meaning “where lines intersect”
|
E.
|
none of the above
|
Scenario 3.
What is the origin of the word
“lambdoid”?
Option list.
A.
|
it is derived from “lambda”, the 11th.
letter of the Greek alphabet, with the symbol “λ”
|
B.
|
it is derived from the shape of the rear end of a
newborn lamb, with legs apart for balance in the shape of an inverted “V”
|
C.
|
it derives from the Norse noun “lam” meaning to hit
|
Scenario 4.
What is the origin of the word
“sagittal”?
Option list.
A.
|
it derives from the Latin verb “sagire” meaning to be
wise
|
B.
|
it derives from the Latin noun “sagitta” meaning
“arrow”
|
C.
|
it derives from the Latin adjective “sagitta” meaning
“pointing north”
|
D.
|
it derives from the Latin adjective “sagitta” meaning
“lacking tension”
|
Scenario 5.
What is the meaning of the word
“coronal”.
Option list.
A.
|
it is the 11th. letter of the Greek alphabet
|
B.
|
it derives from the Latin “corona” meaning “crown”.
|
C.
|
it derives from the sun’s corona, meaning equator
|
Scenario 6.
What is the definition of
“vertex”?
Option list.
A.
|
the most prominent part of the occiput
|
B.
|
the area around the posterior fontanelle
|
C.
|
the area bounded by the anterior fontanelle and the
posterior fontanelle
|
D.
|
the area bounded by the anterior & posterior
fontanelles and the parietal bones
|
E.
|
the area bounded by the anterior & posterior
fontanelles and the parietal eminences
|
F.
|
the area bounded by the anterior & posterior
fontanelles and the parietal cardinals
|
Scenario 7.
What is the definition of the
anterior fontanelle?
Option list.
A.
|
the anterior end of the sagittal suture
|
B.
|
the area where the sagittal and coronal sutures meet
|
C.
|
the area between the frontal and parietal bones
|
D.
|
the posterior end of the sagittal suture
|
E.
|
the area between the parietal bones and the occiput
|
Scenario 8.
What is the definition of the
posterior fontanelle?
Option list.
A.
|
the anterior end of the
sagittal suture
|
B.
|
the area where the sagittal
and lambda sutures meet
|
C.
|
the area between the frontal
and parietal bones
|
D.
|
the posterior end of the
sagittal suture
|
E.
|
the area between the parietal
bones and the occiput
|
Scenario 9.
How many other fontanelles are
there?
A.
|
0
|
B.
|
2
|
C.
|
3
|
D.
|
4
|
E.
|
6
|
Scenario 10.
What is the falx cerebri?
Option list.
A.
|
an area of dura mater at the back of the skull like a
roof over the cerebellum
|
B.
|
is an artefact on ultrasound suggesting the presence of
cerebral tissue where there is none
|
C.
|
is the horizontal fibrous platform on which the
cerebellum rests
|
D.
|
is a crescent-shaped fold of dura mater separating the
cerebral hemispheres
|
Scenario 11.
What is the importance of the
falx cerebri in relation to delivery, particularly breech delivery?
Option list.
A.
|
the falx cerebri is inserted into the tentorium
cerebelli and traction on the base of the skull may lead to tentorial tears
and intracranial bleeding
|
B.
|
the falx cerebri is inserted into the bone of base of
the skull and traction on the base of the skull may lead to tears of the falx
and intracranial bleeding
|
C.
|
the falx cerebri is inserted into the tentorium
cerebelli and traction on the base of the skull may lead to tentorial tears leaving
the cerebellum unsupported and liable to trauma
|
Scenario 12.
What diameter presents to the
pelvis with vertex presentation?
Option list.
A.
|
suboccipito-bregmatic
|
B.
|
suboccipito-frontal
|
C.
|
occipito-frontal
|
D.
|
mento-vertical
|
E.
|
submento-bregmatic
|
Scenario 13.
What diameter presents to the
pelvis with typical occipito-posterior position?
Option list.
A.
|
suboccipito-bregmatic
|
B.
|
suboccipito-frontal
|
C.
|
occipito-frontal
|
D.
|
mento-vertical
|
E.
|
submento-bregmatic
|
Scenario 14.
What diameter presents to the
pelvis with brow presentation?
Option list.
A.
|
suboccipito-bregmatic
|
B.
|
suboccipito-frontal
|
C.
|
occipito-frontal
|
D.
|
mento-vertical
|
E.
|
submento-bregmatic
|
Scenario 15.
What diameter presents to the
pelvis with mento-anterior face presentation?
Option list.
A.
|
suboccipito-bregmatic
|
B.
|
suboccipito-frontal
|
C.
|
occipito-frontal
|
D.
|
mento-vertical
|
E.
|
submento-bregmatic
|
Scenario 16.
What diameter presents to the
pelvis with mento-posterior face presentation?
Option list.
A.
|
suboccipito-bregmatic
|
B.
|
suboccipito-frontal
|
C.
|
occipito-frontal
|
D.
|
mento-vertical
|
E.
|
submento-bregmatic
|
Scenario 17.
What is the average length of
the suboccipito-bregmatic diameter in a term baby?
Option list.
A.
|
9.0 cm.
|
B.
|
9.5 cm.
|
C.
|
10.0 cm.
|
D.
|
10.5 cm.
|
E.
|
11.0 cm.
|
F.
|
11.5 cm.
|
G.
|
12.0 cm.
|
H.
|
12.5 cm.
|
I.
|
13.0 cm.
|
J.
|
13.5 cm.
|
K.
|
14.0 cm.
|
Scenario 18.
What is the average length of
the suboccipito-frontal diameter in a term baby?
Option list.
A.
|
9.0 cm.
|
B.
|
9.5 cm.
|
C.
|
10.0 cm.
|
D.
|
10.5 cm.
|
E.
|
11.0 cm.
|
F.
|
11.5 cm.
|
G.
|
12.0 cm.
|
H.
|
12.5 cm.
|
I.
|
13.0 cm.
|
J.
|
13.5 cm.
|
K.
|
14.0 cm.
|
Scenario 19.
What is the average length of
the occipito-frontal diameter in a term baby?
Option list.
A.
|
9.0 cm.
|
B.
|
9.5 cm.
|
C.
|
10.0 cm.
|
D.
|
10.5 cm.
|
E.
|
11.0 cm.
|
F.
|
11.5 cm.
|
G.
|
12.0 cm.
|
H.
|
12.5 cm.
|
I.
|
13.0 cm.
|
J.
|
13.5 cm.
|
K.
|
14.0 cm.
|
Scenario 20.
What is the average length of
the mento-vertical diameter in a term baby?
Option list.
A.
|
9.0 cm.
|
B.
|
9.5 cm.
|
C.
|
10.0 cm.
|
D.
|
10.5 cm.
|
E.
|
11.0 cm.
|
F.
|
11.5 cm.
|
G.
|
12.0 cm.
|
H.
|
12.5 cm.
|
I.
|
13.0 cm.
|
J.
|
13.5 cm.
|
K.
|
14.0 cm.
|
Scenario 21.
What is the average length of
the submento-bregmatic diameter in a term baby?
Option list.
A.
|
9.0 cm.
|
B.
|
9.5 cm.
|
C.
|
10.0 cm.
|
D.
|
10.5 cm.
|
E.
|
11.0 cm.
|
F.
|
11.5 cm.
|
G.
|
12.0 cm.
|
H.
|
12.5 cm.
|
I.
|
13.0 cm.
|
J.
|
13.5 cm.
|
K.
|
14.0 cm.
|
28. EMQ. Early pregnancy complications. Diagnoses
to exclude.
Lead-in.
The following scenarios relate to early pregnancy.
For each, select the diagnosis you most want to exclude.
Pick one option from the option list.
Each option can be used once, more than once or not at
all.
Option list.
A. Complete
miscarriage.
B. Incomplete
miscarriage.
C. Missed
miscarriage.
D. Pregnancy
in a uterine horn.
E. Ectopic
pregnancy.
F. OHSS.
G. Ovarian
torsion.
H. Ovarian
cyst accident.
I. Hydatidiform
mole.
J. Listeriosis.
K. Toxoplasmosis.
L. Crohn’s
disease
M. Ulcerative
colitis.
N. Duodenal
ulceration.
O. Pulmonary
embolism.
P. Pneumothorax.
Q. Coronary
thrombosis.
R. None of
the above.
Scenario 1.
A 35-year-old primigravida is seen in the EPU with
vaginal bleeding and severe left iliac fossa pain. The pregnancy occurred after
four cycles of IVF and embryo transfer was performed six weeks ago. Her β-hCG
is >1,000 iu/l. An ultrasound scan showed an intra-uterine pregnancy of an
appropriate size for the gestation. Normal fetal heart activity was noted. No
adnexal masses were seen.
Scenario 2.
A 25-year-old woman with known PCOS is seen in the early
pregnancy unit after an episode of slight vaginal bleeding. Her LMP was 10
weeks ago. An ultrasound scan shows an intra-uterine pregnancy with CRL of 6
mm. No fetal heart activity is seen.
Scenario 3.
A GP phones for advice. She is conducting her morning surgery.
A nulliparous woman at 6 weeks’ gestation has returned from
France where she has enjoyed the local food, particularly unpasteurised soft
cheese and pork meats. She has presented with diarrhoea and mild abdominal
pain. A β-hCG is 25 iu/l. She is concerned about listeriosis and toxoplasmosis,
about which she has read.
Scenario 4.
A 30-year-old parous woman attends the EPU with vaginal
bleeding and lower abdominal pain. An ultrasound scan shows a 30 mm.
intra-uterine sac but no evidence of fetal heart activity.
Scenario 5.
A 45-year-old para
6 is admitted to the A&E department with 6 weeks’ amenorrhoea. A β-hCG is
positive. She complains of retrosternal pain and has a history of heartburn and
acid reflux. Her BMI is 30. She smokes 40 cigarettes daily and has COAD.
29. EMQ. Early
pregnancy complications. Management.
Lead-in.
The
following scenarios relate to early pregnancy. For each, select the most
appropriate answer from the option list.
Each
option can be used once, more than once or not at all.
Option List.
A. Admit as an emergency case.
B. Counsel and arrange TVS in 1 week.
C. Counsel and arrange TV colour Doppler
scan.
D. Counsel re expectant management.
E. Explain diagnosis and counsel re MEUC
and SEUC.
F. Explain diagnosis and counsel re
expectant management and MEUC and SEUC.
G. Explain diagnosis and counsel re expectant management, MEUC
and SEUC and refer to the EPU.
H. Explain diagnosis and counsel re treatment options with
accent on the relative merits of SEUC and refer to the EPU.
I. Explain diagnosis and counsel re treatment options with
accent on the relative merits of MEUC and refer to the EPU.
J. Explain diagnosis and refer to the
EPU for PUL protocol.
K. Explain diagnosis and refer to the
EPU for PUV protocol.
L. Manage as ectopic pregnancy until
proven otherwise.
M. Arrange progesterone assay.
N. Arrange AFC.
O. Arrange AMH assay.
P. Arrange serial hCG monitoring for 48
hours.
Q. Administer anti-D immunoglobulin.
R. Administer ergometrine 0.5 mg i.m.
S. Prescribe mifepristone.
T. Prescribe misoprostol for vaginal
use.
U. Continue with routine booking.
V. None of the above.
Scenario 1.
A nulliparous woman attends the booking clinic at 8 weeks’
gestation. An ultrasound scan shows a missed miscarriage of a size commensurate
with the gestation. What will be your management?
Scenario 2.
A nulliparous woman attends the booking clinic at 8 weeks’
gestation. An ultrasound scan shows a missed miscarriage of a size commensurate
with the gestation. She has had two previous pregnancies; both resulted in 1st.
trimester miscarriage. What will be your management?
Scenario 3.
A primigravid woman attends the A&E department with abdominal
pain and vaginal bleeding. A home pregnancy test was +ve 1 week ago; the date
of the LMP is uncertain. What will be your management?
Scenario 4.
A 40-year old woman is pregnant for the first time. Her periods
have been erratic for 12 months and she has occasional hot flushes. She attends
the A&E department with abdominal pain and vaginal bleeding. The bleeding
is slight and her condition is good. An hCG is +ve and a TVS shows an
incomplete miscarriage. What will be your management?
Scenario 5.
A 35-year-old woman has had two normal pregnancies. She attends
the booking clinic after an unplanned conception. Her hCG is +ve. A TVS shows
endometrial thickening but no evidence of intra-uterine pregnancy. No pelvic
abnormality is seen. What will be your management?
Scenario 6.
A 35-year-old woman has had two normal pregnancies. She attends
the booking clinic after an unplanned conception. Her hCG is +ve. A TVS shows a
15 mm. intra-uterine sac, but no fetus or yolk sac. What will be your
management?
Scenario 7.
A 35-year-old woman has had two normal pregnancies. She attends
the booking clinic after an unplanned conception. Her hCG is +ve. A TVS shows a
30 mm. intra-uterine sac, but no fetus. What will be your management?
Scenario 8.
A 35-year-old woman has had two normal pregnancies. She attends
the booking clinic after an unplanned conception. Her hCG is +ve. A TVS shows
an intra-uterine fetus with crown rump length of 5 mm., but no evidence of
fetal heart activity. What will be your management?
Scenario 9.
A 35-year-old woman has had two normal pregnancies. She attends
the booking clinic after an unplanned conception. Her hCG is +ve. A TVS shows
an intra-uterine fetus with crown rump length of 6 mm. Fetal heart activity is
seen. What will be your management?
Scenario 10.
A 35-year-old woman attends the A&E department at 6 weeks’
gestation with pain and bleeding. She became pregnant after IVF. An ultrasound
scan shows a viable intrauterine pregnancy of a size compatible with the
gestation. What will be your management?
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