Monday 24 July 2017

Tutorial 24th. July 2017

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49
EMQ. Appendicitis & pregnancy
50
SBA. Fetal origins of adult disease
51
EMQ. Drugs in O&G 1
52
EMQ. Androgen insensitivity syndrome

Question 49. Appendicitis in pregnancy (AIP)
Abbreviations.
AIP
Appendicitis in pregnancy
CRP
C reactive protein
CT
computed tomography, also known as computerised tomography
RLQP
right lower quadrant pain
RUQP
right upper quadrant pain

Question 1.
Lead-in. What is the approximate incidence of appendicitis in pregnancy?
Option List
A.       
1 in 500
B.       
1 in 1,000
C.       
1 in 2,000
D.       
1 in 5,000
E.        
1 in 10,000
Question 2.
Lead-in. When is appendicitis in pregnancy most common?
Option List
A.       
first trimester
B.       
second trimester
C.       
trimester
D.       
1st. and 2nd. stages of labour
E.        
in the hours after the 3rd. stage of labour
F.        
during the puerperium
Question 3.
Lead-in. What eponymous title is given to the surface marker for the appendix?
Option List
A.       
McBarney’s point
B.       
MacBurney’s point
C.       
McBurney’s point
D.       
MacBorney’s point
E.        
McBorney’s point
Question 4.
Lead-in. Where is the point referred to in the above question?
Option List
A.       
1/3 of the way along the line joining the anterior superior iliac spine and umbilicus
B.       
1/2 of the way along the line joining the anterior superior iliac spine and umbilicus
C.       
2/3 of the way along the line joining the anterior superior iliac spine and umbilicus
D.       
1/3 of the way along the line joining the left and right anterior superior iliac spines
E.        
1/2 of the way along the line joining the left and right anterior superior iliac spines
Question 5.
Lead-in.
Which, if any, of the following statements are true about the person after whom the point in the above questions is named?
Statements
A.       
he spent 2 years as a postgraduate working in Berlin, London, Paris and Vienna
B.       
he was Professor of surgery at the Roosevelt hospital, New York from 1889 to 1894
C.       
he presented his classical paper on appendicitis to the NY Surgical Society in 1889
D.       
he was a transvestite
E.        
he died of a heart attack while on a hunting trip
Question 6.
Lead-in.
Pick the best option from the list below in relation to right lower quadrant pain in appendicitis in the pregnant and non-pregnant.
Option List
A
comparative figures for the pregnant and non-pregnant are unknown due to the rarity of appendicitis in pregnancy
B
RLQP is as common in the pregnant as in the non-pregnant
C
RLQP is less common in the pregnant
D
RLQP is more common in the pregnant
E
RLQP is rare in pregnancy
Question 7.
Lead-in.
Pick the best option from the list below in relation to right upper quadrant pain in appendicitis in the pregnant and non-pregnant.
Option List
A
comparative figures for the pregnant and non-pregnant are unknown due to the rarity of appendicitis in pregnancy
B
RUQP is ½ as common in the pregnant as in the non-pregnant
C
RUQP is as common in the pregnant as in the non-pregnant
D
RUQP is twice as common in the pregnant as in the non-pregnant
E
RUQP is four times as common in the pregnant as in the non-pregnant
Question 8.
Lead-in.
Pick the best option from the list below in relation to nausea in appendicitis in the pregnant and non-pregnant.
Option List
A
comparative figures for the pregnant and non-pregnant are unknown due to the rarity of appendicitis in pregnancy
B
nausea is as common in the pregnant as in the non-pregnant
C
nausea is less common in the pregnant
D
nausea is more common in the pregnant
E
nausea is rare in pregnancy
Question 9.
Lead-in.
Which condition did CMACE say should be excluded in women presenting acutely with gastrointestinal symptoms?
Option List
A
aortic dissection
B
appendicitis
C
Caesarean section scar pregnancy
D
ectopic pregnancy
E
pancreatitis
F
ovarian torsion
Question 10.
Lead-in.
Pick the best option from the list below in relation to abdominal guarding in appendicitis in the pregnant and non-pregnant.
Option List
A
comparative figures for the pregnant and non-pregnant are unknown due to the rarity of appendicitis in pregnancy
B
abdominal guarding is as common in the pregnant as in the non-pregnant
C
abdominal guarding is less common in the pregnant
D
abdominal guarding is more common in the pregnant
E
abdominal guarding is rare in pregnancy
Question 11.
Lead-in.
Pick the best option from the list below in relation to rebound tenderness in appendicitis in the pregnant and non-pregnant.
Option List
A
comparative figures for the pregnant and non-pregnant are unknown due to the rarity of appendicitis in pregnancy
B
rebound tenderness is as common in the pregnant as in the non-pregnant
C
rebound tenderness is less common in the pregnant
D
rebound tenderness is more common in the pregnant
E
rebound tenderness is rare in pregnancy
Question 12.
Lead-in.
Pick the best option from the list below in relation to fever in appendicitis in the pregnant and non-pregnant.
Option List
A
comparative figures for the pregnant and non-pregnant are unknown due to the rarity of appendicitis in pregnancy
B
fever is as common in the pregnant as in the non-pregnant
C
fever is less common in the pregnant
D
fever is more common in the pregnant
E
fever is rare in pregnancy
Question 13.
Lead-in. How useful is the finding of leucocytosis in making the diagnosis of AIP?
Option List
A.       
sine qua non
B.       
very useful
C.       
not very useful
D.       
I don’t know
Question 14. How useful is the finding of a raised CRP level in the diagnosis of AIP?
Option List
A.       
sine qua non
B.       
very useful
C.       
not very useful
D.       
I don’t know
Question 15. Lead-in
What are the ultrasound features of appendicitis?
Option List
A
appendix with diameter > 0.6 mm.
B
appendix with diameter > 1 cm.
C
blind-ending tubular structure
D
non-compressible tubular structure
E
none of the above
Question 16.
Lead-in. What figures do W&M give for sensitivity & specificity for US diagnosis of appendicitis?
Option List

Sensitivity
Specificity
A
≥65%
≥80%
B
≥75%
≥85%
C
≥86%
≥97%
D
≥91%
≥98%
E
≥95%
≥95%
Question 17.
Lead-in. Which, if any, of the following statements are true about CT scanning for the diagnosis of AIP?
Option List
A
CT scanning has sensitivity > 85% and specificity >95%
B
CT scanning exposes mother and fetus to radiation doses of little concern
C
CT scanning has replaced ultrasound scanning for AIP
D
CT scanning is not of proven value after inconclusive ultrasound scanning
E
CT scanning is of proven value and most useful  after inconclusive ultrasound scanning
Question 18.
Lead-in. Which, if any, of the following statements are true about MRI scanning for the diagnosis of AIP?
Option List
A
MRI scanning has sensitivity > 90% and specificity >97%
B
MRI scanning exposes mother and fetus to radiation doses of little concern
C
MRI scanning has replaced ultrasound scanning for AIP
D
MRI scanning is not of proven value after inconclusive ultrasound scanning
E
MRI scanning is of proven value and most useful  after inconclusive ultrasound scanning
Question 19
Lead-in. Which, if any, of the following statements are true about the complications of AIP?
Option List
A
fetal loss rate in uncomplicated AIP is about 1.5%
B
fetal loss rate in AIP complicated by peritonitis is about 6%
C
fetal loss rate in AIP complicated by perforation of the appendix is up to 36%
D
pre-term delivery rates increase in AIP complicated by perforation of the appendix
E
a low level of suspicion should apply to the diagnosis of AIP in relation to surgical intervention
Question 20
Lead-in. Which, if any, of the following statements are true about surgery for AIP?
Option List
A
laparotomy should be done through a grid-iron incision with the mid-point the surface marker for the appendix in the right iliac fossa
B
laparotomy should be done through a right paramedian incision starting at the level of the umbilicus
C
about 35% of laparotomies show no evidence of appendicitis
D
the appendix should be removed even if it looks normal
E
antibiotic therapy is an alternative to surgery in early cases of AIP
Question 21
Lead-in. Which, if any, of the following statements are true about surgery for AIP?
Option List
A
laparotomy should be done through a grid-iron incision with the mid-point the surface marker for the appendix in the right iliac fossa
B
laparotomy should be done through a right paramedian incision starting at the level of the umbilicus
C
about 35% of laparotomies show no evidence of appendicitis
D
the appendix should be removed even if it looks normal
E
antibiotic therapy is an alternative to surgery in early cases of acute AIP
Question 22
Lead-in. Which, if any, of the following statements are true about surgery for AIP?
Option List
A
laparoscopic appendicectomy is an acceptable alternative to laparotomy, but only in the 1st. trimester
B
laparoscopic appendicectomy is an acceptable alternative to laparotomy, but only in the 1st. & 2nd. trimesters
C
laparoscopic appendicectomy is an acceptable alternative to laparotomy, at all gestations
D
there is evidence that laparoscopic appendicectomy is associated with doubling of the rate of fetal loss

TOG has the following questions. Make sure you have read the article: It is now open-access.
“Appendicitis in pregnancy: how to manage and whether to deliver.” Polly Weston & Paul Moroz. TOG. April 2015. Vol 17, Issue 2; Pages 105–10. Make sure you can answer the questions, which are open-access.
Appendicitis is a likely diagnosis in pregnancy when,
1.     ultrasound shows a non-compressible blind-ending tube in the right iliac fossa measuring 10 mm in diameter. T/F
2.     a patient presents with right-sided abdominal pain, constipation and malaise. T/F
In the diagnosis of appendicitis in pregnancy,
3.     ultrasound is the best method for imaging in a morbidly obese patient. T/F
4.     MRI has the greatest specificity of all imaging modalities. T/F
With regard to the management of a pregnant patient with appendicitis,
5.     it should be operative if the diagnosis is certain. T/F
6.     it should primarily aim to reduce any delay in surgical intervention. T/F
7.     it should not involve appendicectomy if the appendix appears normal at the time of surgery. T/F
8.     it should include delivery of the fetus regardless of gestation if the patient is critically ill. T/F
9.     some cases may be treated with antibiotics alone. T/F
General anaesthesia for pregnant women undergoing appendicetomy,
10.   carries an approximately 25-fold increased risk of complications than regional anaesthesia. T/F
11.   has temporary effects on the fetus as all induction and maintenance agents cross the placenta. T/F
12.   has a uterotonic effect. T/F
Surgery for appendicetomy in pregnancy,
13.   increases the rate of miscarriage. T/F
14.   has the lowest risk to the fetus when performed in the second trimester. T/F
15.   should be delayed until antenatal corticosteroids are given (in the absence of severe maternal
sepsis) if the gestation is critical. T/F
Concerning acute appendicitis in pregnancy,
16.   it is the most common cause of acute surgical abdomen. T/F
17.   it most commonly occurs in the first trimester. T/F
18.   it has a fetal loss rate exceeding 50% if the appendix perforates. T/F
With regard to imaging as an investigation for appendicitis in pregnancy,
19.   the primary goal is to rule out differential diagnoses. T/F
20.   the secondary goal is to reduce the negative appendicectomy rate. T/F

Question 50. Fetal origins of adult disease.
Abbreviations.
ADHD:  attention-deficit, hyperactivity disorder
Lead in.
These questions relate to disease in adults resulting from events during fetal, infant and child development.
Scenario 1.
What eponymous title is given to the concept that adverse intra-uterine conditions predispose to the development of disease in adulthood?
Option List                               
F.        
the Barker hypothesis
G.       
the Baker’s dozen
H.       
the Broadbank theory
I.         
PIPAD: Placental Insufficiency Programmes Adult Disease
J.         
SIMCARD: Stop In-utero Malnutrition to Conquer Adult-resulting Disease
Scenario 2.
Which other term is used for the concept that adverse intra-uterine conditions predispose to the development of disease in adulthood?
Option List                               
A.       
FDAD: fetal determination of adult disease
B.       
FIAD:   fetal influences on adult disease
C.       
FIDAD: fetal and infancy determinants of adult disease
D.       
FIGO:   fetal influences on genomic outcomes
E.        
FP:       fetal programming
Scenario 3.
Which of the following is thought to increase the risk of adult disease?
Option List                               
A.       
low birthweight
B.       
low birthweight followed by poor weight gain in infancy and childhood
C.       
low birthweight followed by poor weight gain in infancy but above-average weight gain in childhood
D.       
above-average birthweight
E.        
above-average birthweight followed by poor weight gain in infancy but above-average weight gain in childhood
F.        
above-average birthweight followed by above-average weight gain in infancy and childhood
Scenario 4.
Which adult diseases are generally believed to be more likely in relation to adverse influences on the fetus, infant and child.
Diseases.
A.       
asthma
B.       
chronic bronchitis
C.       
coronary heart disease
D.       
diabetes type I
E.        
diabetes type 2
F.        
hypertension
G.       
Mendelson’s syndrome
Option List                               
A.       
A + B + C + D
B.       
A + B + C + E
C.       
A + B + C + E + F + G
D.       
B + C + E + F + G
E.        
C + E + F
Scenario 5.
What adult condition has been linked to raised maternal c-reactive protein levels?
Option List                               
A.       
asthma
B.       
ADHD
C.       
autism
D.       
inflammatory bowel disease
E.        
schizophrenia

Question 51.  Drugs in O&G 1.
Lead-in. The following scenarios relate to drugs & hypertension in pregnancy.
Pick one option from the option list. Each option can be used once, more than once or not at all.
Abbreviations.
ACE:              angiotensin-converting enzyme
ACEI:            angiotensin-converting enzyme inhibitor
ARA:             angiotensin II receptor antagonist
HG:               hyperemesis gravidarum
IUGR:            intra-uterine growth retardation
LDA:              low-dose aspirin
MAOI:          monoamine oxidase inhibitor
Option list.
a)         False.
b)        True.
c)         5
d)        10
e)         15
f)          18
g)         20
h)        24
i)           contraindicated in the months before pregnancy
j)           contraindicated in the 1st. trimester
k)         contraindicated in the 2nd. trimester
l)           contraindicated in the 3rd. trimester
m)      contraindicated in all trimesters
n)        not contraindicated in pregnancy
o)        contraindicated in breastfeeding
p)        not contraindicated in breastfeeding
q)        an acute, severe illness like rheumatoid arthritis
r)          an acute, severe illness with encephalopathy and acute fatty liver
s)         an acute, severe illness with gastro-intestinal tract bleeding
t)      there is insufficient information to be able to provide advice
Scenario 1.
When are ACE inhibitors contraindicated in pregnancy?
Scenario 2.
When are ARAs contraindicated in pregnancy?
Scenario 3.
Can St. John’s Wort (SJW) be used in pregnancy?
Scenario 4.
Methyldopa is an acceptable option for the treatment of gestational hypertension. True / False.
Scenario 5.
Spironolactone is contraindicated in pregnancy. True/False
Scenario 6.
Furosemide is an acceptable option in the management of gestational hypertension. True / False.
Scenario 7.
When are thiazide diuretics contraindicated in pregnancy?
Scenario 8.
Salbutamol is contraindicated for the management of premature labour. True / False.
Scenario 9.
Ergometrine is an integral part of active management of the 3rd. stage.  True / False.
Scenario 10.
When is aspirin contraindicated in pregnancy & the puerperium?
Scenario 11.
When are NSAID’s contraindicated in pregnancy and why?
Scenario 12.
Pethidine: adverse neonatal effects are most likely if the drug is administered in the six hours before birth.  True / False.
Scenario 13.
Pethidine: what is the half-life in the mature neonate?
Scenario 14.
Pethidine is contraindicated in those taking MOAIs or who have taken them in the previous 2 months. 
Scenario 15.
Pethidine is relatively contra-indicated when there is significant blood loss.  True / False.
Scenario 16.
Pethidine has greater analgesic effect in labour than Diamorphine.                  True / False.
Scenario 17.
What is Reye’s syndrome and which family of drugs is particularly linked?
Scenario 18.
What is “torsades de pointes” and when is it of importance in the management of HG?

Question 52. Topic. Androgen insensitivity syndrome.
Abbreviations.
AIS:             androgen insensitivity syndrome
Question 1.
Lead-in. What is the estimated prevalence of AIS?
Option List
A.       
2-5 per 100,000 boys at birth
B.       
5-10 per 100,000 girls at birth
C.       
2-5 per 100,000 genetic males at birth
D.       
5-10 per 100,000 genetic females at birth
E.        
none of the above.
Question 2.
Lead-in
Which of the following sub-types of AIS do not exist?
Sub-types
1.        
complete AIS
2.        
incomplete AIS
3.        
mild AIS
4.        
partial AIS
5.        
total AIS
Option List
A.       
1
B.       
2
C.       
3
D.       
4
E.        
5
F.        
1 + 3
G.       
2 + 3
H.       
2 + 5
I.         
3 + 5
J.         
4 + 5
Question 3.
Lead-in
How common is partial AIS?
Option List
A.       
at least as common as complete AIS
B.       
at least as common as total AIS
C.       
less common than mild AIS
D.       
as common as incomplete AIS
E.        
none of the above.
Question 4.
Lead-in
How common is incomplete AIS?
Option List
A.       
at least as common as complete AIS
B.       
at least as common as total AIS
C.       
less common than mild AIS
D.       
as common as partial AIS
E.        
none of the above.
Question 5.
Lead-in
How common is mild AIS?
Option List
A.       
at least as common as complete AIS
B.       
at least as common as total AIS
C.       
less common than complete AIS
D.       
as common as partial AIS
E.        
none of the above.
Question 6.
Lead-in
No more prevalence!!
What is the mode of inheritance of AIS?
Option List
A.       
autosomal dominant
B.       
autosomal recessive
C.       
X-linked dominant
D.       
X-linked recessive
E.        
mitochondrial
Question 7.
Lead-in
What proportion of AIS is due to new mutations?
Option List
A.       
0%
B.       
1 – 20%
C.       
21 – 40%
D.       
41-60%
E.        
61-80%
Question 8.
Lead-in
Which gene is involved in AIS?
Option List
A.       
androgen receptor gene
B.       
aromatase receptor gene
C.       
androstenedione gene
D.       
oestrogen receptor gene
E.        
none of the above
Question 9.
Lead-in
How many mutations have been described of the gene which is involved in AIS?
Option List
A.       
0-10
B.       
11-100
C.       
101-200
D.       
201-300
E.        
>300
Question 10.
Lead-in
Which is the most common clinical presentation in AIS?
Option List
A.       
ambiguous genitalia
B.       
precocious puberty
C.       
premature menopause
D.       
primary amenorrhoea
E.        
secondary amenorrhoea
Question 11.
Lead-in
Which of the following are more common in AIS?
Option List
A.       
anlagen
B.       
coarctation of the aorta
C.       
“coast of Maine” pigmentation pattern
D.       
renal tract anomalies
E.        
none of the above.
Question 12.
Lead-in
A woman of 20 is found to have AIS. She has a pre-pubertal sister. What is the chance that the sister also has AIS, assuming that the condition is not due to a new mutation in the elder sister?
Option List
A.       
1 in 1
B.       
1 in 2
C.       
1 in 3
D.       
1 in 4
E.        
1 in 16
Question 13.
Lead-in
What is the risk of the gonads becoming malignant in AIS?
Option List
A.       
10%
B.       
20%
C.       
30%
D.       
> 30%
E.        
accurate risk not known


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