28th. August 2017.
72
|
Claire Candelier. Diabetes. Trainee
assessment.
|
73
|
EMQ. Caesarean section. NICE CG 132
|
74
|
EMQ. Aneuploidy screening.
|
72. Diabetes. Trainee assessment. Claire Candelier.
73. Caesarean section. NICE CG 132
Abbreviations.
cART: combination
anti-retroviral treatment.
CDUS: colour Doppler
ultrasound scan.
HAART: highly active
anti-retroviral therapy.
HCV: hepatitis C virus.
HSV: herpes simplex
virus.
MOD: mode of delivery.
MPA: morbid placental
adherence.
MRI: magnetic resonance
imaging.
MTCT: mother-to-child
transmission.
NVD: normal vaginal
delivery.
pCs planned Caesarean
section.
pvd planned vaginal
delivery.
PVL: plasma viral load.
SROM: spontaneous rupture of
membranes.
VBAC: vaginal birth after
Caesarean section.
Option list.
There is none, to make you think!
Scenarios.
1)
MPA is suspected on a routine 20 week scan
in a woman who has had two LSCSs. What advice should she be given in relation
to the value of colour Doppler US and MRI?
2)
What advice is
given about women who are infected with hepatitis B?
a a woman is
known to have HIV. When should a decision be taken about MOD?
b. at what
gestation should pCs be done as part of management of HIV in pregnancy?
c. at what
gestation should pCs be done in the woman with HIV, if the grounds are
obstetric or the woman’s wish, but not part of the management of HIV?
d. what advice
about MOD should be given to a woman on cART with PVL <50 HIV RNA copies/mL at 36 weeks?
e. what advice
about MOD should be given to a woman on cART with PVL of 200 HIV RNA copies/mL at 36 weeks?
f. what advice
about MOD should be given to a woman on cART with PVL of 300 HIV RNA copies/mL at 36 weeks?
g. what advice
about MOD should be given to a woman on cART with PVL of 400 HIV RNA copies/mL at 36 weeks?
h. what advice
about MOD should be given to a woman on cART with PVL of 600 HIV RNA copies/mL at 36 weeks?
i. a woman with
HIV has been advised that normal delivery is recommended. What additional
interventions should be offered when she goes into labour?
k. what is an
elite controller?
1
|
member of the staff of Black
Rod in the House of Lords
|
2
|
crowd marshal at the Members’
Pavilion at Lord’s Cricket Ground.
|
3
|
Gentleman Usher at Buckingham
Palace party
|
4
|
one of the anti-retroviral
drugs that are essential components of HAART.
|
5
|
individual who is infected
with HIV but maintains low viral and healthy CD4 counts long-term with ART.
|
6
|
individual who is infected
with HIV but maintains low viral and healthy CD4 counts long-term without
ART.
|
l. a woman is
taking zidovudine monotherapy. Her PVL is <50 HIV RNA copies/mL at 36 weeks?
What advice would you give re MOD?
m. a woman is
taking zidovudine monotherapy. Her PVL is 200 HIV RNA copies/mL at 36 weeks?
What advice would you give re MOD?
n. a woman is
taking zidovudine monotherapy. Her PVL is 500 HIV RNA copies/mL at 36 weeks?
What advice would you give re MOD?
o. a woman is an
elite controller. What advice will you give re MOD?
3)
What advice is
given about women who are infected with hepatitis C
4)
What advice is
given about women who are infected with HIV?
5)
What advice is given about women who are
infected with HIV + hepatitis B?
6)
What advice is
given about women who are infected with HIV + hepatitis C
7)
A woman with HIV
takes HAART and has a PVL < 50 copies per ml. She wishes Caesarean section
for non-obstetric reasons. She has been counselled and Caesarean section has
been agreed. At what gestation should it be done?
8)
What advice should
be given to the woman with HSV infection in pregnancy?
9)
What is the risk
of MTCT after primary HSV infection in the 3rd. trimester?
10)
A woman presents
with genital herpes at 36 weeks’ gestation in her first pregnancy. As far as
she is aware, this is her first episode of HSV infection. What is the chance
that it is a recurrent infection?
11)
A woman presents
with genital herpes at 36 weeks’ gestation in her third pregnancy. As far as
she is aware, this is her first episode of HSV infection. What is the chance
that it is a recurrent infection?
12)
A woman presents with genital herpes at 36
weeks’ gestation in her first pregnancy. As far as she is aware, this is her
first episode of HSV infection. What test should be done to clarify whether it
is a 1ry. or recurrent infection?
13)
A woman presents with genital herpes at 36
weeks’ gestation in her first pregnancy. As far as she is aware, this is her first
episode of HSV infection. Swabs are taken from the skin lesions and blood is
taken for HSV type-specific antibodies. She goes into labour at 38 weeks before
the results of the HSV type specific antibody tests are available. What advice
should be given re mode of delivery?
14)
A woman presents
with genital herpes at 36 weeks’ gestation in her first pregnancy. As far as
she is aware, this is her first episode of HSV infection. Swabs are taken from
the skin lesions and blood is taken for HSV type-specific antibodies and
confirm 1ry. infection. She goes into labour with intact membranes at
38 weeks and declines Cs. What action should be taken with regard to anti-viral
treatment?
15)
A woman presents
in labour at 38 week’s gestation, 2 weeks after a 1ry. infection
with genital HSV. She declines Caesarean section, but opts for antiviral
treatment for her and the baby. Which drug should be considered and in what
doses?
16)
A woman presents
in labour at 38 week’s gestation, 2 weeks after a 1ry. infection
with genital HSV. She had SROM 6 hours before.
17)
A woman presents
in early labour at 38 weeks’ gestation. She has a history of recurrent genital
HSV. She has a typical herpetic blister on the vulva. What risk of neonatal
infection will you quote in the discussion?
18)
A woman presents
in labour at term with lesions and a history that are typical of 1ry.
genital HSV infection. Which invasive procedures, if any, should be avoided?
19)
A woman with a
history of recurrent genital herpes presents in labour at 40 weeks with a
typical vulval herpetic blister. Which invasive procedure, if any, should be avoided?
20)
A baby is born by
Caesarean section after maternal 1ry. genital herpes one month
before. Which, if any, of the following are appropriate?
Option
list.
A. liaise with the neonatal unit
B. normal postnatal care of the baby with examination at 24
hours, then discharge if well and feeding is established.
C. swabs of skin, conjunctiva, oropharynx and rectum for HSV
PCR
D. lumbar puncture for evidence of HSV
E. parents to be educated re good hand hygiene
F. i.v. acyclovir, 20 mg/kg 8 hourly until active infection is
ruled out.
G. strict infection control procedures should be put in place
for both mother and baby.
H. breastfeeding should be discouraged because of the presence
of HSV in breast milk.
I.
parents advised to
seek medical help if they have concerns, in particular, skin, eye or mucous
membrane lesions, lethargy, irritability or poor feeding
21)
A baby is born
normally after maternal 1ry. genital herpes one month before. The
mother had declined C section and intends to breast feed. Which, if any, of the
following are appropriate? Option list.
J.
liaise with the
neonatal unit
K. normal postnatal care of the baby with examination at 24
hours, then discharge if well and feeding is established.
L. swabs of skin, conjunctiva, oropharynx and rectum for HSV
PCR
M. lumbar puncture for evidence of HSV
N. parents to be educated re good hand hygiene
O. i.v. acyclovir, 20 mg/kg 8 hourly until active infection is
ruled out.
P. strict infection control procedures should be put in place
for both mother and baby.
Q. breastfeeding should be discouraged because of the presence
of HSV in breast milk.
R. parents advised to seek medical help if they have concerns,
in particular, skin, eye or mucous membrane lesions, lethargy, irritability or
poor feeding,
S. involvement of child protection service.
22)
A baby is born by
Caesarean section after maternal 1ry. genital herpes one month
before. Which, if any, of the following are appropriate?
Option
list.
T. liaise with the neonatal unit
U. normal postnatal care of the baby with examination at 24
hours, then discharge if well and feeding is established.
V. swabs of skin, conjunctiva, oropharynx and rectum for HSV
PCR
W. lumbar puncture for evidence of HSV
X. parents to be educated re good hand hygiene
Y. i.v. acyclovir, 20 mg/kg 8 hourly until active infection is
ruled out.
Z. strict infection control procedures should be put in place
for both mother and baby.
AA. breastfeeding should be discouraged because of the presence
of HSV in breast milk.
BB. parents advised to seek medical help if they have concerns,
in particular, skin, eye or mucous membrane lesions, lethargy, irritability or
poor feeding
23)
What proportion of
neonatal HSV infection is thought to be due to infection after birth?
24)
What steps should
be taken to reduce the risk of neonatal HSV infection?
25)
A primigravida
attends for booking. She requests Caesarean section. There are no clinical
grounds. Outline your management.
26)
A woman with BMI
> 50 should be offered Caesarean section. True/ False.
27)
When should
prophylactic antibiotics in relation to the timing of the operation?
28)
A woman has had
her 3rd. Caesarean section. She wants to know the advice you would
give re the risks of subsequent vaginal delivery.
29) What are the key aspects of induction of general
anaesthesia for unplanned Cs?
30) What should be done about thromboprophylaxis for women
having Cs?
31) Which abdominal incision is
recommended for Cs?
A
|
William
Fletcher Shaw
|
B
|
Victor
Bonney
|
C
|
Ignaz
Semmelweis
|
D
|
Joel-Cohen
|
E
|
Pfannenstiel
|
32) Separate scalpels should be used
for the skin and subsequent incisions to reduce infection. True/False.
33) If the lower segment is
well-formed, blunt dissection should be used to extend the initial uterine
incision. True / False.
34) What is the risk of fetal
laceration?
A
|
0.1%
|
B
|
0.5%
|
C
|
1%
|
D
|
2%
|
E
|
5%
|
35) Routine use of forceps to deliver
the head is acceptable practice. True / False.
36) I.v. syntometrine is the
recommended oxytocic. True / False.
37) Which of the following statements
reflects the advice in CG132 about delivery of the placenta.
A
|
Crede’s
manoeuvre is the recommended routine method for DOP
|
B
|
Leopold’s manoeuvre is the recommended routine method
for DOP
|
C
|
Steptoe’s
manoeuvre is the recommended routine method for DOP
|
D
|
CCT
is the recommended routine method for DOP
|
E
|
MROP
manoeuvre is the recommended routine method for DOP
|
38) Co-amoxiclav is on the list of
recommended antibiotics in CG132 for routine prophylaxis at Cs. True / False.
39) Repair of the uterus is best done
with the uterus exteriorised. True / False.
40) CG132 advises that single or
double-layer closure of the lower segment are equivalent and closure is a
matter of choice for the surgeon. True / False.
41) CG132 advises closure of both
visceral and parietal peritoneum. True / False.
42) Mass closure with a
non-absorbable suture should be used for closure of mid-line incisions. True /
False.
43) What is the suggested threshold
for closure of the subcutaneous fat?
Subcutaneous
fat thickness
|
|
A
|
1
cm.
|
B
|
2
cm.
|
C
|
3
cm.
|
D
|
4
cm.
|
E
|
≥ 5
cm.
|
44) Liberal use of subcutaneous
drains is encouraged to reduce wound infection rates. True / False.
45) When choosing an antibiotic for
prophylactic use at Cs, what infections should particularly be considered?
46) Staff should be silent
immediately before and after the birth of the baby as hearing the mother’s
voice as the first ex-utero experience encourages bonding. True / False.
74. EMQ. Aneuploidy screening.
Lead-in.
The following scenarios relate to screening for
aneuploidy.
Pick one option from the option list.
Each option can be used once, more than once or not at
all.
Abbreviations.
Ds:
|
Down’s syndrome.
|
FASP:
|
Fetal Anomaly Screening Programme.
|
MSAFP:
|
maternal
serum alpha-fetoprotein.
|
NSC:
|
|
PAPP-A
|
pregnancy-associated plasma protein A.
|
uE2
|
unconjugated oestradiol.
|
uE3
|
unconjugated oestriol.
|
Scenario 1.
Which of the following
statements are included in the WHO criteria for a good screening test?
Statements.
1.
|
The condition should be
important
|
2.
|
There should be a
recognisable latent or early symptomatic stage
|
3.
|
The natural course of the
condition should be adequately understood
|
4.
|
There must be a suitable test
that is acceptable to the population to be screened
|
5.
|
There must be an accepted,
effective treatment for those identified by screening
|
6.
|
Diagnostic and treatment
facilities must exist
|
7.
|
There must be an agreed
policy about which of those identified by screening are to be treated
|
8.
|
The cost of screening,
diagnosis and treatment must be valid within the budget for overall medical
care
|
Option list.
A.
|
1 + 2 + 3 + 4 + 5 + 6
|
B.
|
1 + 2 + 5 + 6 + 7 + 8
|
C.
|
1 + 2 + 3 + 4 + 5 + 8
|
D.
|
1 + 5 + 6 + 7 + 8
|
E.
|
1 + 2 + 5 + 6 + 7 + 8
|
F.
|
1 + 2 + 3 + 4 + 5 + 6 + 8
|
G.
|
1 + 2 + 3 + 4 + 5 + 7 + 8
|
H.
|
All of the above
|
Scenario 2.
What is the latest NSC
criterion for the minimum sensitivity of the combined 1st trimester
test?
Option list.
A.
|
≥ 75%
|
B.
|
≥ 80%
|
C.
|
≥ 85%
|
D.
|
≥ 87.5%
|
E.
|
≥ 90%
|
F.
|
≥ 92.5%
|
G.
|
≥ 95%
|
H.
|
≥ 97.5%
|
I.
|
Scenario 3.
What is the latest NSC
criterion for the maximum false +ve rate for the combined 1st
trimester test?
Option list.
A.
|
≥ 10%
|
B.
|
≥ 9%
|
C.
|
≥ 8%
|
D.
|
≥ 7%
|
E.
|
≥ 6%
|
F.
|
≥ 5%
|
G.
|
≥ 4%
|
H.
|
≥ 3%
|
I.
|
≥ 2%
|
J.
|
≥ 1%
|
K.
|
≥ 0.5
|
Scenario 4.
What is the latest NSC
criterion for the minimum sensitivity of the 2nd. trimester
quadruple test?
Option list.
A.
|
≥ 75%
|
B.
|
≥ 80%
|
C.
|
≥ 85%
|
D.
|
≥ 87.5%
|
E.
|
≥ 90%
|
F.
|
≥ 92.5%
|
G.
|
≥ 95%
|
H.
|
≥ 97.5%
|
I.
|
none of the above
|
Scenario 5.
What is the latest NSC
criterion for the maximum false +ve rate for the 2nd. trimester
quadruple test?
Option list.
A.
|
≥ 10%
|
B.
|
≥ 9%
|
C.
|
≥ 8%
|
D.
|
≥ 7%
|
E.
|
≥ 6%
|
F.
|
≥ 5%
|
G.
|
≥ 4%
|
H.
|
≥ 3%
|
I.
|
≥ 2%
|
J.
|
≥ 1%
|
K.
|
≥ 0.5
|
Scenario 6.
Which of the following markers
are used in the 1st. trimester combined test?
Markers
1
|
beta-hCG
|
2
|
free beta-hCG
|
3
|
hCG
|
4
|
inhibin A
|
5
|
inhibin B
|
6
|
MSAFP
|
7
|
PAPP-A
|
8
|
PAPP-B
|
9
|
uE2
|
10
|
uE2
|
Option list.
A.
|
beta-hCG + free beta-hCG +
hCG +inhibin A + inhibin B + MSAFP + PAPP-A + PAPP-B + uE2 + uE3
|
B.
|
beta-hCG + free beta-hCG +
hCG +inhibin A + inhibin B + MSAFP + PAPP-A + PAPP-B + uE2 + uE3
|
C.
|
beta-hCG + free beta-hCG +
hCG +inhibin A + inhibin B + MSAFP + PAPP-A + PAPP-B + uE2 + uE3
|
D.
|
beta-hCG + free beta-hCG +
hCG +inhibin A + inhibin B + MSAFP + PAPP-A + PAPP-B + uE2 + uE3
|
E.
|
beta-hCG + free beta-hCG +
hCG +inhibin A + inhibin B + MSAFP + PAPP-A + PAPP-B + uE2 + uE3
|
F.
|
beta-hCG + free beta-hCG +
hCG +inhibin A + inhibin B + MSAFP + PAPP-A + PAPP-B + uE2 + uE3
|
G.
|
beta-hCG + free beta-hCG +
hCG +inhibin A + inhibin B + MSAFP + PAPP-A + PAPP-B + uE2 + uE3
|
H.
|
beta-hCG + free beta-hCG +
hCG +inhibin A + inhibin B + MSAFP + PAPP-A + PAPP-B + uE2 + uE3
|
I.
|
beta-hCG + free beta-hCG +
hCG +inhibin A + inhibin B + MSAFP + PAPP-A + PAPP-B + uE2 + uE3
|
J.
|
beta-hCG + free beta-hCG +
hCG +inhibin A + inhibin B + MSAFP + PAPP-A + PAPP-B + uE2 + uE3
|
K.
|
beta-hCG + free beta-hCG +
hCG +inhibin A + inhibin B + MSAFP + PAPP-A + PAPP-B + uE2 + uE3
|
L.
|
beta-hCG + free beta-hCG +
hCG +inhibin A + inhibin B + MSAFP + PAPP-A + PAPP-B + uE2 + uE3
|
M.
|
beta-hCG + free beta-hCG +
hCG +inhibin A + inhibin B + MSAFP + PAPP-A + PAPP-B + uE2 + uE3
|
N.
|
beta-hCG + free beta-hCG +
hCG +inhibin A + inhibin B + MSAFP + PAPP-A + PAPP-B + uE2 + uE3
|
Scenario 7.
Which of the following markers
are used in the 2nd. trimester quadruple test?
Markers & option list as for the previous question.
Scenario 8.
What is the approximate
age-related risk of Ds at term for a woman of 21?
Option list.
A.
|
1 in 20
|
B.
|
1 in 35
|
C.
|
1 in 50
|
D.
|
1 in 85
|
E.
|
1 in 100
|
F.
|
1 in 200
|
G.
|
1 in 350
|
H.
|
1 in 500
|
I.
|
1 in 1,000
|
J.
|
1 in 1,500
|
K.
|
none of the above
|
Scenario 9.
What is the approximate
age-related risk of Ds at term for a woman of 25?
Option list. As for question 8.
Scenario 10.
What is the approximate age-related
risk of Ds at term for a woman of 30?
Option list. As for question 8.
Scenario 11.
What is the approximate
age-related risk of Ds at term for a woman of 35?
Option list. As for question 8.
Scenario 12.
What is the approximate
age-related risk of Ds at term for a woman of 40?
Option list. As for question 8.
Scenario 13.
What is the approximate
age-related risk of Ds at term for a woman of 45?
Option list. As for question 8.
Scenario 14.
What is the approximate
age-related risk of Ds at term for a woman of 50?
Option list. As for question 8.
Scenario 15.
A woman
books at 10 weeks in her 1st. pregnancy.
A scan
shows a single pregnancy of a correct size for the gestation.
What Ds
screening should be offered?
Option list.
A.
|
amniocentesis
|
B.
|
cell-free fetal DNA
|
C.
|
chorionic villus biopsy
|
D.
|
combined 1st. trimester
screening
|
E.
|
ductus venosus imaging
|
F.
|
magnetic resonance imaging
|
G.
|
quadruple biochemical screening
|
H.
|
pre-implantation genetic
diagnosis
|
I.
|
ultrasound scan for crown-rump
length
|
J.
|
ultrasound for normal variants
|
K.
|
ultrasound normality scan in
2nd. trimester
|
L.
|
none of the above
|
Scenario 16.
A woman
books at 10 weeks in her 1st. pregnancy.
A scan
shows a twin pregnancy of a correct size for the gestation.
What Ds
screening should be offered?
Option list.
|
|
amniocentesis
|
B.
|
cell-free fetal DNA
|
C.
|
chorionic villus biopsy
|
D.
|
combined 1st. trimester
screening
|
E.
|
ductus venosus imaging
|
F.
|
magnetic resonance imaging
|
G.
|
quadruple biochemical screening
|
H.
|
pre-implantation genetic
diagnosis
|
I.
|
ultrasound scan for crown-rump
length
|
J.
|
ultrasound for normal variants
|
K.
|
ultrasound normality scan in
2nd. trimester
|
L.
|
none of the above
|
Scenario 17.
A woman
books at 10 weeks in her 1st. pregnancy.
A scan
shows a single pregnancy of a correct size for the gestation.
What
screening should be offered for Edward’s and Patau’s syndromes.
Option list.
|
|
amniocentesis
|
B.
|
cell-free fetal DNA
|
C.
|
chorionic villus biopsy
|
D.
|
combined 1st. trimester
screening
|
E.
|
ductus venosus imaging
|
F.
|
magnetic resonance imaging
|
G.
|
quadruple biochemical screening
|
H.
|
pre-implantation genetic
diagnosis
|
I.
|
ultrasound scan for crown-rump
length
|
J.
|
ultrasound for normal variants
|
K.
|
ultrasound normality scan in
2nd. trimester
|
L.
|
none of the above
|
Scenario 18.
A woman books at 15 weeks in
her 1st. pregnancy.
A scan shows a twin pregnancy
of a correct size for the gestation.
What Ds screening should be offered?
Option list.
|
|
amniocentesis
|
B.
|
cell-free fetal DNA
|
C.
|
chorionic villus biopsy
|
D.
|
combined 1st. trimester
screening
|
E.
|
ductus venosus imaging
|
F.
|
magnetic resonance imaging
|
G.
|
quadruple biochemical screening
|
H.
|
pre-implantation genetic
diagnosis
|
I.
|
ultrasound scan for crown-rump
length
|
J.
|
ultrasound for normal variants
|
K.
|
ultrasound normality scan in
2nd. trimester
|
L.
|
none of the above
|
Scenario 19.
A woman books at 15 weeks in
her 1st. pregnancy.
A scan shows a twin pregnancy
of a correct size for the gestation.
What Ds screening should be
offered?
Option list.
|
|
amniocentesis
|
B.
|
cell-free fetal DNA
|
C.
|
chorionic villus biopsy
|
D.
|
combined 1st. trimester
screening
|
E.
|
ductus venosus imaging
|
F.
|
magnetic resonance imaging
|
G.
|
quadruple biochemical screening
|
H.
|
pre-implantation genetic
diagnosis
|
I.
|
ultrasound scan for crown-rump
length
|
J.
|
ultrasound for normal variants
|
K.
|
ultrasound normality scan in
2nd. trimester
|
L.
|
none of the above
|
Scenario 20.
A woman books at 15 weeks in
her 1st. pregnancy.
A scan shows a single pregnancy
of a correct size for the gestation.
What screening should be
offered for Edward’s and Patau’s syndromes?
Option list.
|
|
amniocentesis
|
B.
|
cell-free fetal DNA
|
C.
|
chorionic villus biopsy
|
D.
|
combined 1st. trimester
screening
|
E.
|
ductus venosus imaging
|
F.
|
magnetic resonance imaging
|
G.
|
quadruple biochemical screening
|
H.
|
pre-implantation genetic
diagnosis
|
I.
|
ultrasound scan for crown-rump
length
|
J.
|
ultrasound for normal variants
|
K.
|
ultrasound normality scan in
2nd. trimester
|
L.
|
none of the above
|
Scenario 21.
Which of the following are
included in the 1st. trimester combined test.
Option list.
A.
|
cffDNA
|
B.
|
conjugated beta-hCG
|
C.
|
free beta-hCG
|
D.
|
inhibin A
|
E.
|
inhibin B
|
F.
|
MSAFP
|
G.
|
nuchal thickness scan
|
H.
|
PAPPA
|
I.
|
UE3
|
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