Tutorial 13th. December 2018

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60	EMQ. Semmelweis, Gordon and Holmes
61	SBA.   Placenta accreta, increta & percreta
62	Roleplay. Cystic fibrosis. Brother has cystic fibrosis.
63	Viva. Cochrane
64	SBA. Androgen insensitivity syndrome

60. EMQ. Semmelweis, Gordon and Holmes.

Semmelweis, Gordon & Holmes.

Lead-in.

Pick one option from the option list.

Each option can be used once, more than once or not at all.

Scenario 1.             

Which, if any, of the following statements are true in relation to Semmelweis?

Option list.

A	his full name was Ignác Fülöp Semmelweis, but he was known to friends as "Naci".
B	he lived from 1818 to 1865
C	he revolutionised understanding of ‘childbed fever’
D	he revolutionised understanding of rheumatic fever
E	he revolutionised understanding of tuberculosis
F	he pioneered proton beam therapy
G	his professional ‘Damascene moment’ came after the death of his colleague, Kolletscha, at the hands of a medical student in 1847
H	his work was vilified by the majority of his professional contemporaries
I	he died in a lunatic asylum
J	he died in a road traffic accident
K	he died at home in bed with his mistress

Scenario 2.             

Which, if any, of the following statements are true in relation to Gordon?

Option list.

A	his full name was Hamish Gordon, but he was known to friends as "Hamy".
B	he lived from 1801 to 1864
C	he revolutionised understanding of ‘childbed fever’
D	he revolutionised understanding of rheumatic fever
E	he revolutionised understanding of tuberculosis
F	he pioneered proton beam therapy
G	his professional ‘Damascene moment’ came after epidemics of erysipelas and puerperal fever in Aberdeen in the late 18th. century
H	his work was vilified by the majority of his professional contemporaries
I	he died in a lunatic asylum
J	he died in a road traffic accident
K	he died at home in bed with his mistress

Scenario 3.             

Which, if any, of the following statements are true in relation to Wendell Holmes?

Option list.

A	his full name was Wendell Holmes, but he was known to friends as "Wellie".
B	he lived from 1801 to 1864
C	he revolutionised understanding of ‘childbed fever’
D	he revolutionised understanding of rheumatic fever
E	he revolutionised understanding of tuberculosis
F	he pioneered proton beam therapy
G	he was a fan of the work of Gordon.
H	his work on childbed fever was vilified by the majority of his professional contemporaries
I	he died in a lunatic asylum
J	he died in a road traffic accident
K	he died at home in bed with his mistress

61. SBA.   Placenta accreta, increta & percreta.

This topic has been chosen to remind you of the existence of UKOSS and the various Reports

Question 1.

Lead-in

Choose the best option from the option list for the definition of placenta accreta.

Option List

A.	Placenta which is difficult to remove, but can be separated digitally
B.	Placental villi  invade the decidua, but not the myometrium
C.	Placental villi  invade the decidua and myometrium but not the serosa
D.	Placental villi  invade the decidua, myometrium and serosa
E.	Placental villi  invade adjacent organs, e.g. the bladder

Question 2.

Lead-in

Choose the best option from the option list for the definition of placenta increta.

Option List

A.	Placenta is difficult to remove, but can be separated digitally
B.	Placental villi  invade the decidua, but not the myometrium
C.	Placental villi  invade the decidua and myometrium but not the serosa
D.	Placental villi  invade the decidua, myometrium and serosa
E.	Placental villi  invade adjacent organs, e.g. the bladder

Question 3.

Lead-in

Choose the best option from the option list for the definition of placenta percreta.

Option List

A.	Placenta is difficult to remove, but can be separated digitally
B.	Placental villi  invade the decidua, but not the myometrium
C.	Placental villi  invade the decidua and myometrium but not the serosa
D.	Placental villi  invade the decidua, myometrium and serosa
E.	Placental villi  invade adjacent organs, e.g. the bladder

Question 4.

Lead-in

What is the approximate incidence of placenta creta in the UK?

Option List

A.	1-2 per   1,000 deliveries
B.	1-2 per   1,000 maternities
C.	1-2 per   5,000 deliveries
D.	1-2 per   5,000 maternities
E.	1-2 per 10,000 deliveries
F.	1-2 per 10,000 maternities

Question 5.

You need to be able to define “maternity” and know why it is important.

What is a “maternity”?

Option List

A.	Any pregnancy, including ectopic pregnancy
B.	Any pregnancy, excluding ectopic pregnancy
C.	Any pregnancy resulting in a live birth
D.	Any pregnancy resulting in live birth or stillbirth
E.	Any pregnancy ending from 24 completed weeks plus any pregnancy resulting in a live birth.

Question 6.

Lead-in

Why is the term “maternity” important.

Option List

A.	We should take best possible care of our pregnant patients
B.	It is used as the denominator in calculations of the maternal mortality rate
C.	It is used as the numerator in calculations of the maternal mortality rate
D.	It is used as the denominator in calculations of the maternal mortality ratio
E.	It is used as the numerator in calculations of the maternal mortality ratio

Question 7.

This question relates to risk factors for placenta accreta

Lead-in

Match each of the risk factors listed below with an adjusted odds ratio from the Option List. Each option can be used once, more than once or not at all.

Note that some of the adjusted odds ratios show a reduced risk.

Risk factors and adjusted odds ratio.

Risk factor	Adjusted odds ratio
BMI > 30
Cigarette smoking in pregnancy
Ethnic group non-white
IVF pregnancy
Maternal age > 35
Parity ≥ 2
PIH or PET
Placenta previa diagnosed pre-delivery
Previous Caesarean section > 1
Previous Caesarean section x 1
Previous uterine surgery – not C. section

Option List

Adjusted odds ratio
0.53
0.57
0.66
0.9
1.0
2.0
3.06
3.4
3.48
10
14
16.31
32.13
65.02
102

Question 8.

Lead-in

This question relates to estimated incidence of placenta creta for various risk factors.

Match the risk factors with the estimated incidence in the option list. Each option can be used once, more than once or not at all.

Risk factors and estimated incidence per 10,000 maternities.

Risk factor	Estimated incidence
No previous C section
≥ 1 C section
Placenta previa not diagnosed pre-delivery
Placenta previa diagnosed pre-delivery
Previous C section but pl previa not diagnosed pre-delivery
Previous C section + pl previa diagnosed pre-delivery

Option List

0.3
0.6
1
3
5
9
108
577
1,000

62. Roleplay. Cystic fibrosis. Brother has cystic fibrosis.

Candidate's Instructions.

This is a roleplay station. You are a year 4 SpR and are in the gynaecology clinic.

The consultant has just left you in charge as she is feeling unwell and has gone to lie down.

Your task is to deal with the patient as you would in real life.

GP referral letter.

Best Medical Centre,

High Road,

Anytown.

Phone: 01882 78998.  E-mail: besthealth@gmail.com

Practice Manager: Mary Wright. B.SC., RGN.

Phone: 01882 78998 ext. 23.

E-mail: MWbesthealth@gmail.com

Re. Mrs. Bonnie Black,

25 Low Road,

Anytown.

DOB: 28 January 1990.

Phone: 07889 888 132.

Dear Doctor,

Please see Mrs Black who is planning her first pregnancy. Her main concern is that her brother has cystic fibrosis.

This was the first time I had met her although she has been registered with us for 5 years – her health is good and she has no history of serious illness or surgery.

I have explained that I don’t know much about the implications of the brother’s cystic fibrosis for her potential pregnancies and that she needs to talk to an expert. I have stressed that the risk of her having a child with cystic fibrosis is high and that she needs to be aware that there is a distinct likelihood that any pregnancy would be likely to be affected and need TOP.

Yours sincerely,

John P. Clatter.

63. Viva. Cochrane.

Candidate’s instructions.

This is a viva about the Cochrane Collaboration.

The examiner will ask 8 questions and give one instruction.

64. SBA. Androgen insensitivity syndrome. AIS.

Question 1.

Lead-in

What is the estimated prevalence of AIS?

Option List

F.	2-5 per 100,000 boys at birth
G.	5-10 per 100,000 girls at birth
H.	2-5 per 100,000 genetic males at birth
I.	5-10 per 100,000 genetic females at birth
J.	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