Thursday 31 August 2017

Tutorial 31st. August 2017


75
Kapilmeet Kaur. Uro-gynaecology tutorial.
76
SBA. Non-invasive prenatal testing. NIPT.
77
SBA.  Sutures and needles.
78
EMQ. Puerperal mental illness

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?






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