30
|
Role-play.
Mechanisms of normal labour & delivery. Explain these to the role-player,
who is a medical student and keen to learn how to do a normal delivery. Your
consultant has said that she needs a clear understanding of the mechanisms
before considering conducting a delivery.
|
31
|
Viva. Laboratory results
|
32
|
EMQ. G6PDD
& G6PD
|
33
|
EMQ. Hepatitis
B
|
34
|
EMQ. Mayer-Rokitansky-KΓΌster-Hauser syndrome
|
30. Role-play.
Normal labour & delivery.
Candidate’s
instructions.
You are the SpR on call for the delivery
unit. It is unusually quiet. The on-call consultant has asked you to explain
normal labour and delivery to a medical student who started with the department
yesterday.
31. Viva.
Laboratory results.
Candidate’s
instructions.
Your
consultant is on annual leave. Her secretary has asked you to look through the
following results and decide what action should be taken in relation to each.
1. +ve MSSU at booking. No symptoms.
2. GTT at 34 weeks. Peak level 11.5.
3. FBC with MCV at booking.
4. Thrombocytopenia at booking. 50,000.
5. Hydatidiform mole after evacuation of suspected miscarriage.
6. Histology after ERPC for incomplete miscarriage: no
trophoblastic tissue.
7. Endometrial cancer: hysteroscopy: thickened endometrium.
Histology: Anaplastic malignancy.
8. Endometrial cancer: MR scan: reaching serosa and upper
endocervical canal.
9. Consultant does lap drainage of normal looking ovarian cyst.
Malignant cells. Nulliparous. Wants children.
10. HVS: trichomonas.
11. Clue cells on smear. 12/52 pregnant.
12. Antenatal discharge: endocervical swab:
chlamydia
13. Actinomyces on smear.
14. Herpes in pregnancy
15. Severe dyskaryosis on cervical smear at
booking.
16. Primary infertility: FSH & LH
at 25 on day 3 of cycle.
17. Primary infertility. FSH 3, LH 12 on day 3 of
cycle.
18. Treated with cabergoline for
prolactin and pituitary adenoma. +ve beta HCG.
19. 3 cm. ovarian cyst.
Ca 125.
32. EMQ.
Glucose-6-phosphate dehydrogenase deficiency.
Abbreviations.
G6PD: glucose-6-phosphatase
deficiency
G6PDD: glucose-6-phosphate
dehydrogenase deficiency
Scenario 1.
What is G6PDD?
There is no option list.
Scenario 2.
What
categories are applied to G6PDD by the WHO? There is no option list.
Scenario 3.
What other
names are commonly used for G6PDD? There is no option list.
Scenario 4.
Which, if any,
of the following statements are true in relation to G6PDD?
Option list.
A
|
it is the most common
enzyme defect in humans
|
B
|
it is the most common
RBC enzyme defect in humans
|
C
|
it is the most common
cause of neonatal jaundice
|
D
|
it is the most common
cause of sickling crises
|
E
|
is a glycogen storage
disorder
|
F
|
most of those with G6PDD
have chronic anaemia
|
Scenario 5.
Approximately
how many people are affected by G6PDD worldwide?
Option list.
A
|
1,000 million
|
B
|
800 million
|
C
|
600 million
|
D
|
400 million
|
E
|
100 million
|
F
|
50 million
|
G
|
20 million
|
H
|
10 million
|
I
|
none of the above
|
Scenario 6.
Which
population has the highest prevalence of G6PDD?
Option list.
A
|
American Amish
|
B
|
Asians
|
C
|
Ashkenazi Jews
|
D
|
Eskimos
|
E
|
Irish Travellers
|
F
|
Kurdistan Jews
|
G
|
Sub-Saharan Africans
|
H
|
Turks
|
I
|
Uzbekistan albinos
|
J
|
None of the above
|
Which, if any, of the following is the
mode of inheritance of G6PDD?
Option
list.
A
|
autosomal dominant
|
B
|
autosomal recessive
|
C
|
mitochondrial pattern
|
D
|
X-linked dominant
|
E
|
X-linked recessive
|
F
|
Y-linked
|
Scenario 8.
Approximately how many mutations of the G6PDD gene have been identified? There is no
option list.
Scenario 9.
Which, if any, of the following is the
mode of inheritance of G6PD?
Option
list.
A
|
autosomal dominant
|
B
|
autosomal recessive
|
C
|
mitochondrial pattern
|
D
|
X-linked dominant
|
E
|
X-linked recessive
|
F
|
Y-linked
|
Scenario 10.
Which
foodstuff can trigger haemolysis in G6PDD and gives us one of the alternative
names for the condition? What is the common name for the foodstuff? Which pest
particularly attacks it? There is no option list.
Scenario 11.
Which, if any,
of the following drugs may cause haemolysis in those with G6PDD?
Option list.
A
|
aspirin
|
B
|
diphenhydramine
|
C
|
nalidixic acid
|
D
|
nitrofurantoin
|
E
|
paracetamol
|
F
|
phenytoin
|
G
|
sulphamethoxazole
|
H
|
trimethoprim
|
33. EMQ.
Hepatitis B and pregnancy.
Abbreviations.
HAV: hepatitis A virus
HBcAg: hepatitis B core antigen
HBeAg: hepatitis B e antigen
HBsAg: hepatitis B surface antigen
HBcAb: antibody to hepatitis B core antigen
HBeAb: antibody to hepatitis B e antigen
HBsAb: antibody to hepatitis B surface antigen
HBIG: hepatitis B immunoglobulin
HBV: hepatitis B virus
HBcAg: hepatitis B core antigen
HBeAg: hepatitis B e antigen
HBsAg: hepatitis B surface antigen
HBcAb: antibody to hepatitis B core antigen
HBeAb: antibody to hepatitis B e antigen
HBsAb: antibody to hepatitis B surface antigen
HBIG: hepatitis B immunoglobulin
HCV: hepatitis C virus
HEV: hepatitis E virus
HSV: herpes simplex virus
VT: vertical transmission
Option list.
A.
|
acyclovir
|
B.
|
divorce
|
C.
|
HBcAg +ve
|
D.
|
HBeAg +ve
|
E.
|
HbsAg +ve
|
F.
|
HBsAg +ve; HBsAb –ve;
HBcAb –ve; HBeAg +ve
|
G.
|
HBsAg +ve; HBsAb –ve on two tests six months apart
|
H.
|
HBsAg -ve; HBsAb -ve on two tests six months apart
|
I.
|
HBsAg -ve; HBsAb +ve; HBcAb –ve
|
J.
|
HBsAg -ve; HBsAb +ve; HBcAb +ve
|
K.
|
HBsAg -ve; HBsAb +ve
|
L.
|
HBsAg +ve; HBcAg +ve
|
M.
|
HBV vaccine
|
N.
|
HBIG
|
O.
|
HBV vaccine + HBIG
|
P.
|
immune as a result of infection
|
Q.
|
immune as a result of vaccination
|
R.
|
not immune
|
S.
|
chronic carrier of HBV infection
|
T.
|
10%
|
U.
|
30%
|
V.
|
50%
|
W.
|
60%
|
X.
|
70-90%
|
Y.
|
soap and boiling water
|
Z.
|
10% dilution of bleach in water
|
AA.
|
10% dilution of formaldehyde in alcohol
|
BB.
|
ultraviolet irradiation
|
CC.
|
yes
|
DD.
|
no
|
EE.
|
HAV
|
FF.
|
HBV
|
GG.
|
HCV
|
HH.
|
HEV
|
II.
|
HSV
|
JJ.
|
none of the above
|
Scenario 1.
An asymptomatic primigravida books at 10 weeks. Her partner had an
acute HBV infection 4 months ago. What results on routine blood testing would
indicate that she has an acute HBV infection?
Scenario 2.
An asymptomatic primigravida books at 10 weeks. Her partner had an
acute HBV infection 4 months ago. What results on routine blood testing would
indicate that she is immune to the HBV as a result of infection?
Scenario 3.
An asymptomatic primigravida books at 10 weeks. Her partner had an
acute HBV infection 4 months ago. What results on routine blood testing would
indicate that she is immune to the HBV as a result of HBV vaccine?
Scenario 4.
An asymptomatic primigravida books at 10 weeks. Her partner had an
acute HBV infection 9 months ago. What results on routine blood testing would
show that she is a chronic carrier of HBV infection?
Scenario 5.
Testing
shows that he is positive for HBsAg, positive for HBcAb but negative for IgM
HBcAb. What does this mean in relation to his HBV status?
Scenario 6.
Testing
shows that he is negative for HBsAg, positive for HBcAb and positive for HBsAb.
What
does this mean in relation to his HBV status?
Scenario 7.
How common is chronic HBV carrier status in UK pregnant women?
Scenario 8.
What is the risk of death from chronic HBV carrier status?
Scenario 9.
A primigravid woman at 8 weeks gestation is found to be non-immune
to HBV. She has recently married and her husband is a chronic carrier. What
should be done to protect her from infection?
Scenario 10.
A woman is a known carrier of HBV. What is the risk of vertical
transmission in the first trimester?
Scenario 11.
What is the risk of the neonate who has been infected by vertical
transmission becoming a carrier without treatment?
Scenario 12.
Should antiviral maternal therapy in the 3rd. trimester
be considered for women with HBeAg or high viral load?
Scenario 13.
How effective is hepatitis B prophylaxis for the neonate in
preventing chronic carrier status as a result of vertical transmission?
Scenario 14.
Can a woman who is a chronic HBV carrier breastfeed safely?
Scenario 15.
Hepatitis
B infection is the most dangerous of the viral hepatitis infections in
pregnancy.
Scenario 16.
A pregnant woman who is not immune to HBV has a partner who is a
chronic carrier. Can HBV vaccine be administered safely in pregnancy?
Scenario 17.
A pregnant woman who is not immune has a partner with acute
hepatitis due to HBV. He cuts his hand and bleeds onto the kitchen table. How
should she clean the surface to ensure that she gets rid of the virus?
Scenario 18.
Is
it true that the presence of HBeAg in maternal blood is a particular risk
factor for vertical transmission? Not really a scenario, but never mind!
Scenario 19.
Does elective Cs before labour and with the membranes intact
reduce the vertical transmission rate?
Scenario 20.
Which hepatitis virus normally produces a mild illness, but
represents a major risk to pregnant women, with a mortality rate of up to 5%?
Scenario 21.
A pregnant woman has a history of viral hepatitis and informs the
midwife at booking that she is a carrier and that she has a significant risk of
cirrhosis and has been advised not to drink alcohol. Which is the most likely
hepatitis virus?
Scenario 22.
Which hepatitis virus is an absolute contraindication to
breastfeeding after appropriate treatment of the infected mother and
prophylaxis for the baby?
Scenario 23.
Which hepatitis virus is linked to an increased risk of obstetric
cholestasis?
34. EMQ.
Mayer-Rokitansky-KΓΌster-Hauser
syndrome (MRKH).
Question 1.
Lead-in.
What are the
main features of MRKH? There is no option list to make life harder.
Question 2.
Lead-in.
Which, if any, are the main secondary features associated with
MRKH?
Option list.
A
|
anosmia
|
B
|
attention-deficit-hyperactivity
syndrome
|
C
|
auditory anomalies
|
D
|
neural tube defects
|
E
|
renal anomalies
|
F
|
skeletal anomalies
|
Question 3.
Lead-in.
How does MRKH
syndrome usually present?
Option list.
A
|
cyclical pain due to
haematometra
|
B
|
delayed puberty
|
C
|
precocious puberty
|
D
|
premature menopause
|
E
|
primary amenorrhoea
|
F
|
recurrent otitis media
|
G
|
recurrent urinary tract
infection
|
H
|
secondary amenorrhoea
|
Question 4.
Lead-in.
Which of the
following chromosome patterns are typical of MRKH?
Option list.
A
|
45XO
|
B
|
45YO
|
C
|
46XX
|
D
|
46XY
|
E
|
47XXX
|
F
|
47XXY
|
Question 5.
Lead-in.
What is the
approximate incidence of MRKH in newborn girls?
Option list.
A
|
~ 1 in 1,000
|
B
|
~ 1 in 2,000
|
C
|
~ 1 in 4,000
|
D
|
~ 1 in 6.000
|
E
|
~ 1 in 8,000
|
F
|
~ 1 in 10,000
|
G
|
~ 1 in 100,000
|
H
|
the figure is unknown
|
I
|
it does not occur
|
Question 6.
Lead-in.
What is the
approximate incidence of MRKH in newborn boys?
Option list.
A
|
~ 1 in 1,000
|
B
|
~ 1 in 2,000
|
C
|
~ 1 in 4,000
|
D
|
~ 1 in 6.000
|
E
|
~ 1 in 8,000
|
F
|
~ 1 in 10,000
|
G
|
~ 1 in 100,000
|
H
|
the figure is unknown
|
I
|
it does not occur
|
Question 7.
Lead-in.
Which of the
following statements are correct in relation to urinary tract anomalies
associated with MRKH?
Option list.
A
|
absent bladder
|
B
|
absent kidney
|
C
|
ectopic ureter
|
D
|
horseface kidney
|
E
|
hypospadias
|
F
|
urinary tract anomalies are
not part of the syndrome
|
Question 8.
Lead-in.
Which of the
following statements are correct in relation to skeletal anomalies associated
with MRKH?
Option list.
A
|
absent thumb
|
B
|
absent big toe
|
C
|
developmental dysplasia of
the hip
|
D
|
Klippel-Feil anomaly
|
E
|
ulnar hypoplasia
|
F
|
vertebral fusion
|
G
|
skeletal anomalies are not
part of the syndrome
|
Question 9.
Lead-in.
Which of the
following statements are correct in relation to auditory anomalies associated
with MRKH?
Option list.
A
|
absent ear
|
B
|
absent stapes
|
C
|
acoustic neuroma
|
D
|
conductive deafness
|
E
|
inductive deafness
|
F
|
stapedial ankylosis
|
G
|
auditory anomalies are not
part of the syndrome
|
Question 10.
Lead-in.
What is the
recommended first-line management for creation of a neovagina.
Option list.
A
|
digital dilatation
|
B
|
marriage to a virile
husband
|
C
|
vaginal balloons
|
D
|
vaginal dilators
|
E
|
vaginoplasty
|
F
|
there is no recommended 1st.
line management
|
Question 11.
Lead-in.
What is what
are the key features of Davydov vaginoplasty?
Option list.
A
|
horseshoe perineal incision
with labial flaps used to create a pouch
|
B
|
creation of space between
bladder and rectum and lining it with amnion
|
C
|
creation of space between
bladder and rectum and lining it with skin graft
|
D
|
creation of space between
bladder and rectum and lining it with sigmoid colon
|
E
|
creation of space between
bladder and rectum and lining it with peritoneum
|
F
|
traction via threads
running to the abdomen from a vaginal bead
|
Question 12.
Lead-in.
What is what
are the key features of McIndoe vaginoplasty?
Option list.
A
|
horseshoe perineal incision
with labial flaps used to create a pouch
|
B
|
creation of space between
bladder and rectum and lining it with amnion
|
C
|
creation of space between
bladder and rectum and lining it with skin graft
|
D
|
creation of space between
bladder and rectum and lining it with sigmoid colon
|
E
|
creation of space between
bladder and rectum and lining it with peritoneum
|
F
|
traction via threads
running to the abdomen from a vaginal bead
|
Question 13.
Lead-in.
What is what
are the key features of Vecchietti vaginoplasty?
Option list.
A
|
horseshoe perineal incision
with labial flaps used to create a pouch
|
B
|
creation of space between
bladder and rectum and lining it with amnion
|
C
|
creation of space between
bladder and rectum and lining it with skin graft
|
D
|
creation of space between
bladder and rectum and lining it with sigmoid colon
|
E
|
creation of space between
bladder and rectum and lining it with peritoneum
|
F
|
traction via threads
running to the abdomen from a vaginal bead
|
Question 14.
Lead-in.
What is what
are the key features of Williams vaginoplasty?
Option list.
A
|
horseshoe perineal incision
with labial flaps used to create a pouch
|
B
|
creation of space between
bladder and rectum and lining it with amnion
|
C
|
creation of space between
bladder and rectum and lining it with skin graft
|
D
|
creation of space between
bladder and rectum and lining it with sigmoid colon
|
E
|
creation of space between
bladder and rectum and lining it with peritoneum
|
F
|
traction via threads
running to the abdomen from a vaginal bead
|
TOG
CPD questions. Mark the answers true or false.
With regard to the MRKH syndrome.
1. there is
failure of development of the mesonephric ducts.
2. the
phenotype and genotype are female.
3. studies
have established a link between the syndrome and the use of diethylstilboestrol
in pregnancy.
4. symmetrical
uterovaginal aplasia is found in type I disorders.
5. renal
abnormalities are seen in more than half of cases.
6. skeletal
abnormalities are reported in up to one-fifth of cases.
7. up to
one-quarter of women have a malformed ear or auditory canal.
8. the close
proximity of the MΓΌllerian and Wolffian duct derivatives to the duct in the
developing embryo explains the higher association of malformations of the kidneys
with this condition.
9. vaginal agenesis is caused by failure of the caudal
part of the MΓΌllerian duct system to develop.
10. magnetic resonance
imaging is the gold standard tool.
11. two-dimensional
ultrasound scanning is not useful for associated renal tract abnormalities.
12. complete
androgen insensitivity syndrome is an important differential diagnosis.
13. the
presence of cyclical abdominal pain will rule out the diagnosis, as it
indicates the presence of functioning endometrium.
With regard to the creation of a neovagina,
14. it is
recommended that treatment is initiated as soon as the diagnosis is made.
15. psychological
support to women undergoing this procedure is of the utmost importance.
16. vaginal
dilators are acceptable as an option for first-line therapy.
17. Ingram’s
modified Frank’s technique involves the use of vaginal dilators.
With regard to the surgical creation of a
neovagina,
18. in the
Davydov procedure the neovagina is lined with peritoneum.
With regard to fertility in women with the
MRKH syndrome,
19. transvaginal
egg retrieval is recognised to be difficult during in vitro fertilisation.
20. the
condition has been shown to be transmissible to the offspring.
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