75
|
Kapilmeet Kaur. Uro-gynaecology
tutorial.
|
76
|
SBA. Non-invasive prenatal testing. NIPT.
|
77
|
SBA.
Sutures and needles.
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78
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EMQ. Puerperal mental illness
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75. Urogynaecology. Kapilmeet Kaur
76. Non-invasive prenatal testing. NIPT.
Abbreviations.
CAH: congenital
adrenal hyperplasia
DSD: disorder
of sexual development
NIPD: non-invasive
prenatal diagnosis
NIPT: non-invasive
prenatal testing
RAADP: routine
antenatal anti-D prophylaxis.
Question 1.
Lead-in
What is
the definition of NIPT?
Option List
A.
|
any test
to detect fetal anomaly, disease or significant problem that does not involve
invasive testing of the mother
|
B.
|
any test to detect fetal anomaly, disease or
significant problem that does not involve invasive testing of the mother,
excluding TVS
|
C.
|
any test for fetal chromosomal anomaly that does not
involve invasive testing of the mother
|
D.
|
any test for fetal chromosome or genetic anomaly that
does not involve invasive testing of the mother.
|
E.
|
none of the above
|
Question 2.
Lead-in
What is
the potential of NIPT using cffDNA?
Option List
A.
|
description
of the full fetal genome
|
B.
|
description of the full fetal genome with the exception
of disorders arising from mitochondrial DNA
|
C.
|
description of the full fetal genome with the exception
of disorders arising from mitochondrial RNA
|
D.
|
description of the full fetal genome and most
structural anomalies
|
E.
|
none of the above
|
Question 3.
Lead-in
Which, if
any, of the following statements is
true?
Option List
A.
|
cffDNA
is found in maternal serum in greater quantities than maternal cell-free DNA
|
B.
|
cffDNA is found in maternal serum in lesser quantities than maternal cell-free
DNA
|
C.
|
the quantity of cffDNA rises throughout pregnancy,
peaking at delivery
|
D.
|
cffDNA diminishes after placental delivery but remains
detectable for at least 6 weeks
|
E.
|
cffDNA diminishes after placental delivery but remains
detectable for at least 1 year
|
Question 4.
Lead-in
Which, if
any, of the following statements is true about cffDNA in maternal blood?
Statements.
1. cffDNA originates in the placenta, not
the fetus
2. cffDNA
originates in fetal squames
3. cffDNA
originates in fetal blood cells
4. cffDNA
occurs in maternal blood due to trans-membrane osmosis
5. cffDNA
occurs in maternal blood due to feto-maternal transfusion
Option List
A.
|
1
|
B.
|
2
|
C.
|
3
|
D.
|
4
|
E.
|
5
|
F.
|
1 + 4
|
G.
|
2 + 4
|
H.
|
2 + 5
|
I.
|
3 + 5
|
Question 5.
Lead-in
Which. if
any, of the following statements are true?
Statements.
1.
tests
using cffDNA are based on detecting paternally-derived fetal DNA in maternal
blood.
2.
tests
using cffDNA are based on detecting maternally-derived fetal DNA in maternal
blood.
3.
tests
using cffDNA are based on detecting DNA from the fetal Y chromosome.
4.
tests
using cffDNA may involve shotgun sequencing.
5.
tests
using cffDNA may involve shotgun nuptials.
Option List
A.
|
1
|
B.
|
2
|
C.
|
3
|
D.
|
4
|
E.
|
5
|
F.
|
1 + 4
|
G.
|
1 + 5
|
H.
|
2 + 4
|
I.
|
2 + 5
|
J.
|
3 + 4
|
K.
|
3 + 5
|
Question 6.
Lead-in
Which. if
any, of the following statements are true?
Option List
A.
|
detection
of the SRY sequence in cffDNA means that the fetus is female
|
B.
|
detection of the SRY sequence in cffDNA means that the
fetus is male
|
C.
|
detection of the SRY sequence in cffDNA means that the
fetus is male unless it has a DSD
|
D.
|
detection of the SRY sequence in cffDNA means that the
fetus has Klinefelter’s syndrome
|
E.
|
detection of the SRY sequence in cffDNA means that the
fetus has 45X0/46XY mosaicism.
|
Question 7.
Lead-in
Which. if
any, of the following statements are true?
Option List
A.
|
Rhesus D
status can be determined accurately from 12 weeks’ gestation using cffDNA
|
B.
|
Rhesus D pseudogene is more common in Africans than
Caucasians
|
C.
|
People with the RhD pseudogene are at risk of isoimmunisation.
|
D.
|
People with the RhDu blood type may be identified as
Rh-ve or Rh+ve on routing testing
|
E.
|
People with the RhDu blood type are particularly prone
to isoimmunisation
|
Question 8.
Lead-in
Which. if
any, of the following statements are true in relation to cffDNA in maternal
blood?
Option List
A.
|
Checking
the fetal RhD status is best left until > 16 weeks’ gestation
|
B.
|
Checking the fetal Kell status is not yet routinely
available
|
C.
|
Checking the fetal Kell status is best left until >
20 week’s gestation
|
D.
|
Routine screening of Rh –ve women for fetal RhD status
reduces the use of RAADP by up to 10%
|
E.
|
Routine screening of Rh –ve women for fetal RhD status
reduces the use of RAADP by up to 40%
|
Question 9.
Lead-in
List the
other situations in which cffDNA in maternal serum can be used for clinical
benefit.
Other questions.
1.
cffDNA levels in maternal blood are raised in pregnancies affected by Down’s
syndrome.
2. screening
for Down’s syndrome using cffDNA has both sensitivity and specificity close to
100%
3. What
is the value of cffDNA in women at risk of having a baby with CAH?
5. What
is the role of amniocentesis if a cffDNA screen for a condition such as cystic
fibrosis proved +ve?
6. cffDNA
screening for achondroplasia and thanatophoric dysplasia is now available on
the NHS for women at risk of an affected baby.
7. What
is meant by “contingent” screening using cffDNA in relation to Down’s syndrome?
8. What
is an “allele”?
9. What
is a “wild-type” allele?
10. What
is the alternative to a “wild-type” allele?
77. Sutures and needles.
Abbreviations
Eas: external anal sphincter
Ias: internal anal sphincter
OASI: obstetric anal sphincter injury
SSI: surgical site infection
Question 1.
Lead-in
What is
the incidence of significant infection of abdominal surgical wounds?
Option List
F.
|
≤ 1%
|
G.
|
≤ 3%
|
H.
|
≤ 5%
|
I.
|
≤ 7%
|
J.
|
≤ 10%
|
Question 2.
Lead-in
Which, if
any, of the following statements are true in relation to SSIs?
Option List
A.
|
pre-operative
showering with antiseptic reduces the rate
|
B.
|
pre-operative chemical depilation of the wound site
halves the rate
|
C.
|
povidone-iodine preparations are superior to those with
chlorhexidine
|
D.
|
alcohol based antiseptic preparations are superior to
aqueous
|
E.
|
antiseptic solutions should be applied using sponge not
swab
|
Question 3.
Lead-in
Why do
alcohol-based solutions carry more risk and how can these risks be minimised?
There is
no option list – write your thoughts and compare them with my answer.
Question 4.
Lead-in
Which of the
following terms are used to categorise suture materials?
Option List
F.
|
natural
|
G.
|
synthetic
|
H.
|
monofilament
|
I.
|
coated
|
J.
|
none of the above
|
Question 5.
Which, if
any, of the following are sources of catgut?
Option List
A.
|
cats
|
B.
|
cows
|
C.
|
kangaroos
|
D.
|
sheep
|
E.
|
whales
|
Question 6.
Lead-in
Which of
the following is closest to being the ideal suture material?
Option list
A.
|
natural
|
B.
|
synthetic
|
C.
|
monofilament
|
D.
|
coated
|
E.
|
none of the above
|
Question 7.
Lead-in
What would
be the key characteristics of the ideal suture?
There is
no option list – write as many as you can dream up.
Question 8.
Lead-in
Which
suture is recommended in GTG 29 for the repair of the anal mucosa in OASIs?
Option List
A.
|
2-0 polyglactin
|
B.
|
3-0 polyglactin
|
C.
|
2-0 PDS
|
D.
|
3-0 PDS
|
E.
|
none of the above
|
Question 9.
Lead-in
Which, if
any, of the following suturing techniques are recommended in GTG 29 for the
repair of the anal mucosa in OASIs?
Option List
A.
|
continuous
suture
|
B.
|
figure of 8 suture
|
C.
|
interrupted sutures with the knot buried beneath the perineal
muscles
|
D.
|
interrupted sutures with the knots in the anal canal
|
E.
|
submucosal suture like a subcuticular suture for skin
|
Question 10.
Lead-in
Which
would be the most suitable suture for repair of the mesosalpinx during tubal
re-anastomosis for reversal of sterilisation after tubal ligation?
Option List
L.
|
Vicryl 0
on a cutting needle
|
M.
|
Vicryl 2-0 on a cutting needle
|
N.
|
Vicryl 2-0 on a round-bodied needle
|
O.
|
Vicryl 3-0 on a cutting needle
|
P.
|
Vicryl 3-0 on a round-bodied needle
|
Question 11.
Lead-in
Which
would be the most suitable suture for the tubal surgery necessary during tubal
re-anastomosis for reversal of sterilisation after tubal ligation?
Option List
A.
|
Vicryl 3-0
on a cutting needle
|
B.
|
Vicryl 3-0 on a round-bodied needle
|
C.
|
Vicryl 5-0 on a cutting needle
|
D.
|
Vicryl 5-0 on a round-bodied needle
|
E.
|
Vicryl 7-0 on a cutting needle
|
F.
|
Vicryl 7-0 on a round-bodied needle
|
Question 12.
Lead-in
You are
performing Caesarean section on a woman who has had 2 previous sections. The
bladder is very adherent. You separate it from the lower segment using sharp
dissection and taking great care. You notice a 1 cm. defect in the dome of the
bladder. The ureteric openings are far from the damage. Which suture would you
use for the repair, assuming that you have the training and expertise to
perform it?
Option List
F.
|
Single-layer
repair using interrupted sutures of 2-0 Vicryl
|
G.
|
Two-layer repair using interrupted sutures of 2-0
Vicryl
|
H.
|
Single-layer
repair using interrupted sutures of 3-0 Vicryl
|
I.
|
Two-layer
repair using interrupted sutures of 3-0 Vicryl
|
J.
|
None of the above
|
Question 13.
Lead-in
You are
performing hysterectomy + bilateral salpingo-oophorectomy for menorrhagia and
extensive endometriosis. After dissecting the right ovary free from
adhesion to the pelvic side-wall, you
detect urine and note that the ureter has been cut. It is suitable for
anastomosis.
Which of
the following would you use for the repair, assuming that you have the training
and expertise to perform it?
Option List
A.
|
Single-layer
repair using interrupted sutures of 2-0 Vicryl
|
B.
|
Two-layer repair using interrupted sutures of 2-0
Vicryl + stent
|
C.
|
Single-layer
repair using interrupted sutures of 3-0 Vicryl
|
D.
|
Two-layer
repair using interrupted sutures of 3-0 Vicryl + stent
|
E.
|
None of the above
|
Question 14.
Lead-in
An obese,
woman of 80 years has a laparotomy for debulking of an ovarian malignancy via a
mid-line incision. Which of the following would be most suitable for closing
the abdomen.
Option List
A.
|
0 Vicryl
to muscle / fascia, 2-0 Vicryl to fat, interrupted 2-0 Vicryl to skin
|
B.
|
0 Vicryl to muscle / fascia, 2-0 Vicryl to fat,
interrupted 2-0 Vicryl to skin + fat drain
|
C.
|
mass closure using 0 Vicryl, interrupted 2-0 Vicryl to
skin
|
D.
|
mass closure using 1 Vicryl, interrupted 2-0 Vicryl to
skin
|
E.
|
mass closure using 0 Prolene, interrupted 2-0 Vicryl to
skin
|
Question 15.
Lead-in
You perform Caesarean section for a woman with a breech
presentation. She had a mid-line lower abdominal scar resulting from a
laparotomy some years before. She has requested that you use this scar and is
aware of the slightly increased risk of dehiscence and hernia formation.
Which of the following best describes your decision re
closing the abdomen.
Option List
A.
|
close
each layer separately using 0 Vicryl, don’t close peritoneum
|
B.
|
mass closure using continuous 0 Prolene, peritoneum not
closed
|
C.
|
mass closure using interrupted 0 Prolene, peritoneum
not closed
|
D.
|
mass closure using continuous 0 Vicryl, peritoneum not
closed
|
E.
|
mass closure using 0 Vicryl, peritoneum closed
|
Question 16.
Lead-in
You perform Caesarean section for a primigravida with a
breech presentation. When you close the uterus, which of the following
statements will govern the technique you use.
Option List
A.
|
the
uterus should be exteriorised to maximise access
|
B.
|
the uterus should be explored digitally to exclude
retained products, e.g. a succenturiate lobe of the placenta
|
C.
|
the uterus should be cleaned out with a swab to remove
any debris
|
D.
|
double-layer closure is recommended
|
E.
|
closure of the pelvic peritoneum is recommended
|
Question 17.
Lead-in
A parous
woman has a normal delivery, then a PPH. All conservative measures fail to
arrest the bleeding and you decide to insert a uterine compression suture.
Which of the following statements would apply to what you do.
Option List
A.
|
place
and inflate an intrauterine balloon before inserting the suture to maximise
the effect.
|
B.
|
exteriorise the uterus to reduce the risk of injury to
bowel when placing sutures
|
C.
|
use 1 Vicryl or 1PDS
|
D.
|
use a curved needle of diameter at least 6 cm.
|
E.
|
none of the above
|
TOG CPD 16.1
Abdominal incisions and sutures in obstetrics and
gynaecology
With respect to the risk of
surgical site infection following abdominal incisions,
1. it is reduced with preoperative antiseptic
showering.
2. it is reduced if the site is depilated
preoperatively.
3. it is increased approximately seven-fold by
morbid obesity.
Which of the following is/are
true about abdominal incisions?
4. In a Pfannenstiel incision, the layers of
the abdominal wall are cut transversely, including the rectus muscle.
5. A Joel-Cohen incision is located slightly
lower than a Pfannenstiel incision.
6. The incidence of wound dehiscence is ↓ with paramedian
compared with median incisions.
7. A caesarean section through the Joel-Cohen incision
carries less postoperative febrile morbidity when compared to that through a Pfannenstiel
incision.
8. A transverse incision is associated with reduced
incidence of wound dehiscence compared with a vertical incision.
9. With regard to skin incisions for
laparoscopic surgery,. those that are more than 7 mm will need formal deep
sheath closure.
Which of the following statements is/are true?
10. The primary function of a suture is to maintain
tissue approximation during healing.
11. Wound infection rate is higher with braided compared
with monofilament sutures.
12. Non-absorbable sutures are associated with reduced
incidence of wound dehiscence.
13. PDS (polydiaxanone) is a braided suture with high
tissue reaction.
14. Polypropylene is a monofilament suture with least
tissue reaction.
15. Vicryl rapide is absorbed in 60–90 days.
With regard to use of staples
for closure,
16. the non-absorbable variety has the highest tensile
strength of any wound closure device.
17. contaminated wounds closed with staples have
a lower incidence of infection compared with those closed with sutures.
18. the absorbable varieties have a tissue
half-life of 10 weeks.
With regard to electrosurgery,
19. it is associated with poor wound healing when used
to incise the skin.
20. the use of a separate scalpel for superficial
and deep incisions is recommended.
78. 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?
