Tutorial 13th. July 2017

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13^th. July  2017.

39	SBA. Ovarian reserve
40	EMQ. Confidentiality and consent.
41	SBA. Coeliac disease & pregnancy
42	EMQ. Anti-D prophylaxis
43	EMQ. Haemophilia A

Question 39. Ovarian reserve.

Abbreviations.

AFC:            antral follicle count

AMH:         anti-Müllerian hormone.

OR:             ovarian reserve.

Question 1.

Lead-in

What is the definition of ovarian reserve?

Option List

A.	Sex-hormone-induced female shyness.
B.	the number of functional oocytes per cubic centimetre of ovarian tissue
C.	the number of oocytes per cubic centimetre of ovarian tissue
D.	the number of remaining oocytes
E.	the proportion of residual to primordial oocytes

Question 2.

Lead-in

What is the definition of the menopause?

Option List

A.	the end of menstruation
B.	the end of menstruation, but not if hysterectomy is the cause
C.	the end of menstruation, but not if endometrial ablation is the cause
D.	the time when periods become infrequent and finally cease
E.	the climacteric

Question 3.

Lead-in

How many periods must be missed for the menopause to be diagnosed?

Option List

A.	6
B.	9
C.	12
D.	24
E.	none of the above

Question 4.

Lead-in

What is the definition of the climacteric?

Option List

A.	the same as “menopause”
B.	the same as the “perimenopause”
C.	the time from the start to the end of vasomotor symptoms
D.	the time from the start of menopausal symptoms to one year after the LMP
E.	I am never going to use this term again, so don’t ask me about it!
F.	none of the above

Question 5.

Lead-in

What is the definition of premature menopause?

Option List

A.	menopause occurring at an earlier age in successive generations
B.	menopause occurring < 50 years
C.	menopause occurring < 45 years
D.	menopause occurring < 40 years
E.	menopause occurring < 35 years

Question 6.

Lead-in

Which of the following conditions is not associated with premature menopause.

Conditions.

1.	45XO/XX mosaicism
2.	Fragile X pre-mutation carrier status
3.	Fragile X full mutation carrier status
4.	galactosaemia
5.	Mayer – Rokitansky – Kuster - Hauser syndrome
6.	Swyer’s syndrome.

Option List

A.	1 + 2 + 4
B.	1 + 2 +  4 + 5
C.	1 + 2 + 4 + 6
D.	1 + 3 + 4
E.	3 + 4 + 5
F.	3 + 5 + 6
G.	all of the conditions
H.	some of the conditions, but I don’t know which
I.	none of the conditions

Question 7.

Lead-in

A woman is a carrier of the Fragile X pre-mutation. What is her risk of premature ovarian failure?

Option List

A.	5%
B.	10%
C.	15%
D.	20%
E.	25%

Question 8.

Lead-in

Where is FSH produced?

Option List

A.	granulosa cells
B.	hypothalamus
C.	pineal gland
D.	anterior pituitary
E.	posterior pituitary

Question 9.

Lead-in

Where is LH produced?

Option List

A.	granulosa cells
B.	hypothalamus
C.	pineal gland
D.	anterior pituitary
E.	posterior pituitary

Question 10.

Lead-in

Where is Inhibin A produced?

Option List

A.	granulosa cells
B.	granulosa cells of small developing follicles
C.	granulosa cells of the dominant follicle and corpus luteum
D.	ovarian stroma
E.	adrenal gland

Question 11.

Lead-in

Where is Inhibin B produced?

Option List

A.	granulosa cells
B.	granulosa cells of small developing follicles
C.	granulosa cells of the dominant follicle and corpus luteum
D.	ovarian stroma
E.	adrenal gland

Question 12.

Lead-in

Where is AMH produced?

Option List

A.	granulosa cells
B.	granulosa cells of small antral follicles
C.	granulosa cells of the pre-antral follicles
D.	dominant follicle and corpus luteum
E.	ovarian stroma

Question 13.

Lead-in

Which if any of the following statements are true?

Statements.

1.	AFC is based on antral follicles up to 2 mm in diameter
2.	AFC is based on antral follicles up to 5 mm in diameter
3.	AFC is based on antral follicles up to 10 mm in diameter
4.	AFC is of proven superiority to AMH assay in assessing OR
5.	AFC + AMH assay is a superior test to AMH assay alone in assessing OR

Option List

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

Question 14.

Lead-in

Which is the best test to measure ovarian reserve?

Option List

A.	early follicular FSH levels
B.	luteal follicular FSH levels
C.	early follicular-phase FSH + LH levels
D.	early follicular-phase AMH levels
E.	early follicular-phase AFC
F.	none of the above

Question 40. Confidentiality & consent.

Lead-in.

The following scenarios relate to confidentiality & consent.

Option list.

This EMQ has no option list. This is to make you decide your answers, which is what you are advised to do in the exam before you look at the option list.

Scenario 1.

A 15-year-old girl attends the TOP clinic requesting TOP. She is assessed as Fraser competent. After full discussion arrangements are made for her admission for TOP. She does not wish her parents to be informed. Her mother attends clinic 1 hour after the child has left. She demands full information about her daughter. The consultant has delegated you to deal with her. What action you will take?

Scenario 2.

A 17-year-old A-level student attends the gynaecology clinic requesting TOP. She is accompanied by her 30-year-old mathematics teacher, who is her lover and wishes to give consent. What action you will take?

Scenario 3.

A 12-year-old girl attends the gynaecology clinic with her mother seeking contraceptive advice. She has an 18-year-old boyfriend whom the parents like and she wishes to start having sex. What action you will take?

Scenario 4.

A 15-year-old girl who is Fraser competent is referred to the gynaecology clinic with a complaint of vaginal discharge. She reveals that she has been having consensual sexual intercourse for six months with her 18-year-old boyfriend. She asks for advice about suitable contraception as she is happy in the relationship and wants to continue to have sex. What action you will take?

Scenario 5.

You are the new oncology consultant and have just operated on the wife of a local General Practitioner for suspected ovarian cancer. The diagnosis is confirmed and you proceed with appropriate surgery. On completion of the operation you go to the surgeon’s room for a coffee. The senior consultant anaesthetist who was not involved in theatre but is the Medical Director and tells you he is a close friend of the woman, asks what the diagnosis and prognosis are. What action you will take?

Scenario 6.

You are phoned by a doctor looking for information about his wife’s results from the booking clinic she attended two weeks ago. He says that she has given consent for disclosure. She has given a history of 2 terminations but no other pregnancies. She is Rhesus negative, but has Rhesus antibodies. What action you will take?

Scenario 7

You are phoned by a doctor looking for information about his wife’s results from the booking clinic she attended two weeks ago. He says that she has given consent for disclosure. Her serology tests have proved +ve for syphilis. You have spoken to the consultant bacteriologist who says that they have run confirmatory tests and they are +ve too. He is sure the woman has active syphilis. What action you will take?

Scenario 8

A 15-year-old girl attends the TOP clinic requesting TOP. She is assessed as Fraser competent. After full discussion arrangements are made for her admission for TOP. She does not wish her parents to be informed despite your best efforts to persuade her. Who will give consent for the procedure?

Scenario 9

An immature 15-year-old girl attends the gynaecology clinic requesting TOP. She is accompanied by her 25-year-old sister who is a lawyer with whom she has been staying since she knew she was pregnant. She does not want her parents to be informed. The girl is assessed as not Fraser competent. The sister says that she is happy to act in loco parentis and to give consent. What action you will take?

Scenario 10

A 25-year-old woman with Down’s syndrome attends the clinic accompanied by her mother. She has menorrhagia and copes badly with the hygiene aspects. The menorrhagia is bad enough for her now to be on treatment for iron-deficiency anaemia. She has tried all the standard medical methods. To complicate the problem, she has become close friends with a young man she has met at College, to which she travels independently each weekday. Her mother fears that she may already be involved in sexual activity and cannot get an accurate answer from her about it. The mother is keen for her to have hysterectomy to deal with both problems. If you agree that the surgery is appropriate, who can give consent?

Scenario 11

A 25-year-old woman with Down’s syndrome is admitted from College after collapsing. The clinical features are of ectopic pregnancy and she states that she has UPSI with her boyfriend of six months. She has tachycardia and hypotension and it is felt that she should have urgent surgery. You reckon that she is not competent to consent for surgery. Who can give consent?

Scenario 12

A 25-year-old woman with Down’s syndrome is admitted from College after collapsing. The clinical features are of ectopic pregnancy and she states that she has UPSI with her boyfriend of six months. She has tachycardia and hypotension and it is felt that she should have urgent surgery. You reckon that she is not competent to consent for surgery. What limits are there on the surgery?

Scenario 13.

You are the SpR on call and are asked to see a 10-year-old child in the A&E department. She has been brought because of vaginal bleeding. She is accompanied by her parents who give a story of her injuring herself falling of her bike. Examination shows vaginal bleeding and you think the hymen looks torn. You suspect sexual abuse and don’t believe the parents’ story. When this is discussed with the parents they say it is impossible and that they do not want involvement of police or social workers. What action will you take?

Scenario 14.

You are the SpR in theatre with your consultant. Mrs Mary White, age 45, has been listed for abdominal hysterectomy and bilateral salpingo-oophorectomy – she has a long history of menorrhagia that has not responded to conservative measures. Her mother had ovarian cancer diagnosed at 55 and died from the disease 3 years later. A 10 cm., solid tumour of the left ovary is found on opening the abdomen. Which of the following options is the correct course of action?

A	close the abdomen, see her to explain the findings and book a follow-up appointment in the gynaecological clinic to discuss further management
B	close the abdomen, arrange to see her to explain the findings and refer to the gynaecological oncologist to discuss further management
C	continue with the operation, but don’t remove the left ovary
D	continue with the operation, removing the uterus and both ovaries and tubes
E	continue with the operation, removing the uterus and both ovaries and tubes and obtaining peritoneal washings
F	ask the gynaecological oncologist to attend to perform definitive surgery on the basis that the cyst is likely to be malignant
G	phone the legal department for advice
H	phone the Court of Protection for advice

Scenario 15.

You are an SpR in theatre with your consultant.

Mrs Mary White, age 45, has been listed for abdominal hysterectomy and bilateral salpingo-oophorectomy – she has a long history of menorrhagia that has not responded to conservative measures. Her mother had ovarian cancer diagnosed at 55 and died from the disease 3 years later.

You perform examination under anaesthesia prior to the abdomen being opened. You find a 10 cm., mass to the left of the uterus. It feels solid. There is no evidence of ascites or other pathology.

 Which of the following options is the correct course of action?

A	Cancel the operation and arrange review in the gynaecology department in 6 weeks
B	Cancel the operation and arrange review by the oncology team
C	Cancel the operation and arrange an urgent scan
D	Continue with the planned procedure
E	Ask the gynaecological oncologist to attend theatre to examine the patient and advise
F	Perform laparoscopy to identify the nature of the mass
G	Phone the legal department

Question 41. Coeliac disease and pregnancy.

Abbreviations.

AGA:                            anti-gliadin antibodies 

CD:                              coeliac disease.

EMA:                           anti-endomysial antibodies. 

FGR:                            Fetal growth restriction.

IgA:                              immunoglobulin A IgG. 

tTGA:                           anti-tissue transglutaminase antibody.

Question 1.

Lead-in

What is coeliac disease?

Option List

F.	allergy to gluten
G.	malabsorption due to large bowel inflammation
H.	an auto-immune disorder triggered by gluten sensitivity causing villous atrophy of the descending colon in individuals with a genetic predisposition
I.	an auto-immune disorder triggered by gluten sensitivity causing villous atrophy of the gastric mucosa in individuals with a genetic predisposition
J.	an auto-immune disorder triggered by gluten sensitivity causing villous atrophy of the small bowel in individuals with a genetic predisposition

Question 2.

Lead-in

What is the prevalence of coeliac disease in women of reproductive age?

Option List

A.	0.1%
B.	0.5%
C.	1-2 %
D.	2-5%
E.	5-10%

Question 3.

Lead-in

Which of the following groups have an increased risk of CD?

Option List

A.	1st. degree relatives of those with CD
B.	those with type 1 diabetes
C.	those with iron deficiency anaemia
D.	those with osteoporosis
E.	those with unexplained infertility

Question 4.

Lead-in

Which of the following are features of CD in the non-pregnant population?

Option List

A.	abdominal bloating and pain
B.	amenorrhoea
C.	anaemia
D.	recurrent miscarriage
E.	unexplained infertility

Question 5.

Lead-in

How do pregnant women with CD present most commonly?

Option List

A	anaemia
B	failure to gain weight in pregnancy
C	intra-uterine growth retardation
D	low BMI
E	no recognised abnormality

Question 6.

Lead-in

Which of the following commonly occur in pregnant women with CD?

Option List

A	anaemia
B	failure to gain weight in pregnancy
C	intra-uterine growth retardation
D	low BMI
E	no recognised abnormality

Question 7.

How should the woman with suspected CD be investigated initially?

Option List

G.	jejunal biopsy
H.	IgA EMA
I.	IgA tTGA
J.	IgA EMA + IgA tTGA
K.	rectal biopsy

Question 8.

Lead-in

Which, if any, of the following statements are true in relation to the woman due to have testing for suspected CD?

Option List

A.	continue with a normal diet.
B.	continue with a normal diet that includes a minimum of 5 gm. gluten daily
C.	continue with a normal diet that includes a minimum of 10 gm. gluten daily
D.	follow a strict gluten-free diet for at least 1 month
E.	follow a strict gluten-free diet for at least 3 months

Question 9.

Lead-in

Which of the following conditions should make consideration of testing for CD sensible?

Option List

A.	amenorrhoea
B.	Down’s syndrome
C.	epilepsy
D.	recurrent miscarriage
E.	Turner’s syndrome
F.	unexplained infertility

Question 10.

Lead-in

How is the diagnosis of CD confirmed after +ve serological testing?

Option List

A.	colonoscopy
B.	enteroscopy
C.	gastroscopy
D.	rectal biopsy
E.	small bowel  biopsy

Question 11.

Lead-in

Which skin condition is particularly associated with CD?

Option List

A.	atopic eczema
B.	dermatitis herpetiformis
C.	dermatitis multiforme
D.	dermatographia
E.	psoriasis

Question 12.

Lead-in

Which of the following are likely to be absorbed less well than normally in women with CD?

Option List

A.	carbohydrate
B.	fat
C.	folic acid
D.	protein
E.	vitamins B12, D & K

Question 13.

Lead-in

What is the appropriate treatment of CD?

Option List

A.	antibiotics: long-term in low-dosage
B.	azathioprine
C.	cyclophosphamide
D.	rectal steroids
E.	none of the above

Question 14.

Lead-in

Which of the following do not contain gluten?

Option List

A.	barley
B.	oats
C.	rapeseed oil
D.	rye
E.	wheat

Question 42. Anti-D prophylaxis.

Lead-in.

The following scenarios relate to Rhesus prophylaxis and anti-D.

Abbreviations.

Ig:               immunoglobulin.

FMF:           feto-maternal haemorrhage.

RAADP:      routine antenatal anti-D prophylaxis.

RBC:           red blood cells.

RhAI:          Rhesus D alloimmunisation.

BSE:            bovine spongiform encephalopathy.

CJD:            Creutzfeldt-Jakob Disease.

Option list.

There is no option list to force good technique!

Scenarios.

1)      What proportion of the Caucasian population in the UK has Rh –ve blood group?         

2)      What proportion of the Rhesus +ve Caucasian population is homozygous for RhD?    

3)      What is the chance of a Rh –ve woman with a Rh +ve partner having a Rh –ve child?

4)      When was routine postnatal anti-D prophylaxis introduced in the UK?  

5)      Where does anti-D for prophylactic use come from?

6)      How many deaths per 100,000 births were due to RhAI up to 1969.   

7)      How many deaths per 100,000 births were due to RhAI in 1990.

8)      Anti-D was in short supply in 1969. Which non-sensitised Rh –ve primigravidae with Rh +ve babies would not be given anti-D as a matter of policy?    

9)      List the possible reasons that a Rhesus –ve mother with a Rhesus +ve baby who does not receive anti-D might not become sensitised?                                                                                                                         

10)   What is the UK policy for the administration of anti-D after a term pregnancy?

11)   What is the alternative name of the Kleihauer test?

12)   What does the Kleihauer test do?

13)   How does the Kleihauer test work and what buzz words should you have in your head?

14)   When should a Kleihauer test be done after vaginal delivery?

15)   What blood specimen should be sent to the laboratory for a Kleihauer test?

16)   What steps should be taken to prevent sensitisation in the woman whose blood group is RhD_u and whose baby is Rh +ve?

17)   The Kleihauer test is of value in helping to decide if antenatal vaginal bleeding or abdominal pain are due to placental abruption, with a +ve test confirming FMH and making abruption highly probable.  True/False

18)   When should anti-D be offered?

19)   When should a Kleihauer test be considered?                                                                               

20)   How often does the word “considered” feature in the GTG?

21)   A Rhesus –ve woman miscarries a Rh +ve fetus at 18 week’s gestation. What should be done about Rhesus prophylaxis?

22)   A Rhesus –ve woman miscarries a Rh +ve fetus at 20 week’s gestation. What should be done about Rhesus prophylaxis?

23)   Which potentially sensitising events are mentioned in the GTG?

24)   What factors are listed in the GTG as particularly likely to cause FMH > 4 ml

25)   A woman has recurrent bleeding from 20 weeks. What should be done about Rh prophylaxis?

26)   What are the key messages about giving RAADP?

Question 43. Haemophilia A.

Lead-in.

The following scenarios relate to haemophilia A, factor VIII deficiency  (HA).

For each, select the most appropriate answer  from the option list.

Each option can be used once, more than once or not at all.

Abbreviations.

CVS:      chorionic villus sampling

HA:        haemophilia A.

Scenario 1.

A woman attends for pre-pregnancy counselling. Her brother has haemophilia A. What is her risk of being a carrier?

Scenario 2 .

A woman attends for pre-pregnancy counselling. Her father has haemophilia A. What is her risk of being a carrier?

Scenario 3.

If she is tested and found to be a carrier, what tests will you arrange for her partner?

Scenario 4.

If she is a carrier, what is the risk to her male offspring?

Scenario 5.

If she is a carrier, what is the risk to her female offspring?

Scenario 6.

If she is a carrier and her partner has haemophilia A, what are the risks to their female offspring?

Scenario 7.

If she is a carrier and her partner has haemophilia A, what are the risks to their male offspring?

Scenario 8.

A lady doctor  has a brother with haemophilia. There is no other FH of haemophilia. The brother has a 20-year-old daughter who is planning pregnancy and phones his sister, the doctor,  to ask what the risk is of his daughter being a carrier.

Scenario 9.

A lady doctor  has a brother with haemophilia. There is no other FH of haemophilia. The brother has a 20-year-old daughter who is planning pregnancy and phones his sister, the doctor,  to ask what the risk is of his daughter’s sons being affected.

Scenario 10.

A lady doctor  has a brother with haemophilia. There is no other FH of haemophilia. The brother has a 20-year-old daughter who is planning pregnancy and phones his sister, the doctor,  to ask what the risk is of his daughter having an affected daughter.

Scenario 11.

A lady doctor  has a brother with haemophilia. There is no other FH of haemophilia. She has a pregnancy with no testing. A son in born. What is the chance that he will be affected?

Scenario 12.

A lady doctor  has a brother with haemophilia. There is no other FH of haemophilia. She has a pregnancy with no testing. A son in born. What is the chance that he is not affected?

Scenario 13

A lady doctor  has a brother with haemophilia. There is no other FH of haemophilia. She has a pregnancy with no testing. A daughter is born. What is the chance she will be a carrier?

Scenario 14

A lady doctor  has a brother with haemophilia. There is no other FH of haemophilia. She is found to be a carrier. What additional tests, if any, should be done because of her carrier status?