Tutorial 9th. January 2020

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44	SBA. Appendicitis in pregnancy
45	EMQ. Kallmann’s syndrome
46	EMQ. Antenatal steroids
47	Structured conversation. MgSO4 use in O&G.
48	MCQ. TOG questions. MgSO4 use.

44.      Appendicitis in pregnancy (AIP)

Abbreviations.

AIP:                     appendicitis in pregnancy

CRP :                   C reactive protein

EFHRM:              electronic fetal heart rate monitoring

KPS:                     “Pregnancy and appendicitis: a systematic review and meta-analysis on the clinical use of MRI in diagnosis of appendicitis in pregnant women” by Mania Kave, Fateme Parooie & Morteza Salarzaei. World J Emergency Surgery 2019. Vol 14, Article number: 37 (2019)

MBRRACE14:     Maternal Mortality Report 2009-12: “Saving Lives, Improving Mothers’ Care”. Published December 2014.

RLQP:                  right lower quadrant pain

RUQP{                 right up:              per quadrant pain

W&M:                “Appendicitis in pregnancy: how to manage and whether to deliver” by Polly Weston & Paul Moroz in TOG. 2015;17: Pages 105–110

Suggested reading.

“Appendicitis in pregnancy: how to manage and whether to deliver” by Polly Weston & Paul Moroz in TOG. 2015;17: Pages 105–110.

W&M give the following for comparative incidences in the pregnant and non-pregnant.

Clinical feature	Incidence in pregnant	Incidence in non-pregnant
Right lower quadrant pain	75%	95%
Right upper quadrant pain	20%	5%
Nausea	85%	90%
Vomiting	70%	70%
Anorexia	65%	90%
Dysuria	8%	2%
Rebound tenderness	80%	90%
Abdominal guarding	50%	90%
Rectal tenderness	45%	45%
Low grade fever	20%	60%

Question  1.            

Lead-in

What is the approximate incidence of appendicitis in pregnancy?

Option List

A.	1 in 500
B.	1 in 1,000
C.	1 in 2,000
D.	1 in 5,000
E.	1 in 10,000

Answer. B. W&M say: “acute appendicitis is suspected in 1/800 pregnancies and confirmed in 1/800 to 1/1500”.

Question  2.            

Lead-in

Is appendicitis more or less common in pregnancy?

Option List

A.	just as common
B.	less common
C.	maybe
D.	more common
E.	no one knows
F.	no one cares

Answer. B. Less common. W&M cite a Swedish paper which compared > 700 women with appendicitis in pregnancy with matched, non-pregnant controls and found an OR of 0.78.

Question  3.            

Lead-in

How is maternal death from appendicitis classified?

Option List

A.	coincidental death
B.	direct death
C.	incidental death
D.	indirect death
E.	none of the above

Answer. D. Indirect death. MBRRACE14 included 2 deaths from appendicitis. There would be some logic in them being deemed coincidental, but they are included with other, non-genital-tract sepsis such as meningitis in the indirect category.

Question  4.            

Lead-in

When is appendicitis in pregnancy most common?

Option List

A.	first trimester
B.	second trimester
C.	trimester
D.	1st. and 2nd. stages of labour
E.	in the hours after the 3rd. stage of labour
F.	during the puerperium

Answer. B. Second trimester. This fact is from W&M, but they don’t give figures.

Question  5.            

Lead-in

What eponymous title is given to the surface marker for the appendix?

Option List

A.	McBarney’s point
B.	MacBurney’s point
C.	McBurney’s point
D.	MacBorney’s point
E.	McBorney’s point

Question  6.            

Lead-in

Where is the point referred to in the above question?

Option List

A.	1/3 of the way along the line joining the anterior superior iliac spine and umbilicus
B.	1/2 of the way along the line joining the anterior superior iliac spine and umbilicus
C.	2/3 of the way along the line joining the anterior superior iliac spine and umbilicus
D.	1/3 of the way along the line joining the left and right anterior superior iliac spines
E.	1/2 of the way along the line joining the left and right anterior superior iliac spines

Question  7.            

Lead-in

Which, if any, of the following statements are true about the person after whom the point in the above questions is named?

Statements

A.	he spent 2 years as a postgraduate working in Berlin, London, Paris and Vienna
B.	he was Professor of surgery at the Roosevelt hospital, New York from 1889 to 1894
C.	he presented his classical paper on appendicitis to the NY Surgical Society in 1889
D.	he was a transvestite
E.	he died of a heart attack while on a hunting trip

Option List

1	A + B + E
2	A + C + E
3	A + B + D
4	A + B + C + D
5	A + B + C + E

Question  8.            

Lead-in.

Pick the best option from the list below in relation to right lower quadrant pain in AIP in the pregnant and non-pregnant.

Option List

A	comparative figures for the pregnant and non-pregnant are unknown due to the rarity of appendicitis in pregnancy
B	RLQP is as common in the pregnant as in the non-pregnant
C	RLQP is less common in the pregnant
D	RLQP is more common in the pregnant
E	RLQP is rare in pregnancy

Question  9.            

Lead-in.

Pick the best option from the list below in relation to right upper quadrant pain in AIP in the pregnant and non-pregnant.

Option List

A	comparative figures for the pregnant and non-pregnant are unknown due to the rarity of appendicitis in pregnancy
B	RUQP is ½ as common in the pregnant as in the non-pregnant
C	RUQP is as common in the pregnant as in the non-pregnant
D	RUQP is twice as common in the pregnant as in the non-pregnant
E	RUQP is four times as common in the pregnant as in the non-pregnant

Question  10.         

Lead-in.

Pick the best option from the list below in relation to nausea in AIP in the pregnant and non-pregnant.

Option List

A	comparative figures for the pregnant and non-pregnant are unknown due to the rarity of appendicitis in pregnancy
B	nausea is as common in the pregnant as in the non-pregnant
C	nausea is less common in the pregnant
D	nausea is more common in the pregnant
E	nausea is rare in pregnancy

Question  11.         

Lead-in.

Which condition did CMACE say should be excluded in women presenting acutely with gastrointestinal symptoms?

Option List

A	aortic dissection
B	appendicitis
C	Caesarean section scar pregnancy
D	ectopic pregnancy
E	pancreatitis
F	ovarian torsion

Question  12.         

Lead-in.

Pick the best option from the list below in relation to abdominal guarding in AIP in the pregnant and non-pregnant.

Option List

A	comparative figures for the pregnant and non-pregnant are unknown due to the rarity of appendicitis in pregnancy
B	abdominal guarding is as common in the pregnant as in the non-pregnant
C	abdominal guarding is less common in the pregnant
D	abdominal guarding is more common in the pregnant
E	abdominal guarding is rare in pregnancy

Question  13.         

Lead-in.

Pick the best option from the list below in relation to rebound tenderness in AIP in the pregnant and non-pregnant.

Option List

A	comparative figures for the pregnant and non-pregnant are unknown due to the rarity of appendicitis in pregnancy
B	rebound tenderness is as common in the pregnant as in the non-pregnant
C	rebound tenderness is less common in the pregnant
D	rebound tenderness is more common in the pregnant
E	rebound tenderness is rare in pregnancy

Question  14.         

Lead-in.

Pick the best option from the list below in relation to fever in AIP in the pregnant and non-pregnant.

Option List

A	comparative figures for the pregnant and non-pregnant are unknown due to the rarity of appendicitis in pregnancy
B	fever is as common in the pregnant as in the non-pregnant
C	fever is less common in the pregnant
D	fever is more common in the pregnant
E	fever is rare in pregnancy

Question  15.         

Lead-in

Question  16.         

How useful is the finding of a raised CRP level in the diagnosis of AIP?

Option List

A.	sine qua non
B.	very useful
C.	not very useful
D.	I don’t know

Question  17.         

Lead-in

What are the ultrasound features of appendicitis?

Option List

A	appendix with diameter > 6 mm.
B	appendix with diameter > 1 cm.
C	blind-ending tubular structure
D	non-compressible tubular structure
E	none of the above

Question  18.         

Lead-in

What figures do W&M give for sensitivity & specificity for US diagnosis of appendicitis?

Option List

	Sensitivity	Specificity
A	≥65%	≥80%
B	≥75%	≥85%
C	≥86%	≥97%
D	≥91%	≥98%
E	≥95%	≥95%

Question  19.         

Lead-in

Which, if any, of the following statements are true about CT scanning for the diagnosis of AIP?

Option List

A	CT scanning has sensitivity > 85% and specificity >95%
B	CT scanning exposes mother and fetus to radiation doses of little concern
C	CT scanning has replaced ultrasound scanning for AIP
D	CT scanning is not of proven value after inconclusive ultrasound scanning
E	CT scanning is of proven value and most useful after inconclusive ultrasound scanning

Question  20.         

Lead-in

Which, if any, of the following statements are true about MRI scanning for the diagnosis of AIP?

Option List

A	MRI scanning has sensitivity > 90% and specificity >97%
B	MRI scanning exposes mother and fetus to radiation doses of little concern
C	MRI scanning has replaced ultrasound scanning for AIP
D	MRI scanning is not of proven value after inconclusive ultrasound scanning
E	MRI scanning is of proven value and most useful after inconclusive ultrasound scanning

Question  21.         

Lead-in

Which, if any, of the following statements are true about the complications of AIP?

Option List

A	fetal loss rate in uncomplicated AIP is about 1.5%
B	fetal loss rate in AIP complicated by peritonitis is about 6%
C	fetal loss rate in AIP complicated by perforation of the appendix is up to 36%
D	pre-term delivery rates increase in AIP complicated by perforation of the appendix
E	a low level of suspicion should apply to the diagnosis of AIP in relation to surgical intervention

Question  22.         

Lead-in

Which, if any, of the following statements are true about surgery for AIP?

Option List

A	laparotomy should be done through a grid-iron incision with the mid-point the surface marker for the appendix in the right iliac fossa
B	laparotomy should be done through a right paramedian incision starting at the level of the umbilicus
C	about 35% of laparotomies show no evidence of appendicitis
D	the appendix should be removed even if it looks normal
E	antibiotic therapy is an alternative to surgery in early cases of acute AIP

Question  23.         

Lead-in

Which, if any, of the following statements are true about surgery for AIP?

Option List

A	laparoscopic appendicectomy is an acceptable alternative to laparotomy, but only in the 1st. trimester
B	laparoscopic appendicectomy is an acceptable alternative to laparotomy, but only in the 1st. & 2nd. trimesters
C	laparoscopic appendicectomy is an acceptable alternative to laparotomy, at all gestations
D	there is evidence that laparoscopic appendicectomy is associated with doubling of the rate of fetal loss

Question  24.         

Lead-in

Which, if any, of the following statements are true about C section in relation to AIP?

Option List

A	C section is rarely necessary
B	C section increases the risk of uterine infection if peritonitis is present
C	C section should be offered if elective C section is planned
D	C section should be considered if the woman is critically ill

Question  25.         

Lead-in

Which, if any, of the following statements are true about the fetal heart rate?

Option List

A	EFHRM should be done pre and post-operatively in surgery for AIP
B	EFHRM should always be done intra-operatively in surgery for AIP
C	the drugs used for GA tend to cause fetal tachycardia
D	the drugs used for GA commonly cause a sinusoidal pattern
E	C section should be done if abnormal EFHRM patterns occur
F	fetal scalp pH sampling should be done if abnormal EFHRM patterns occur
G	fetal blood sampling should be done if abnormal EFHRM patterns occur

TOG questions.

Appendicitis is a likely diagnosis in pregnancy when,

1.     ultrasound shows a non-compressible blind-ending tube in the right iliac fossa measuring 10 mm in diameter.

2.     a patient presents with right-sided abdominal pain, constipation and malaise.

In the diagnosis of appendicitis in pregnancy,

3.     ultrasound is the best method for imaging in a morbidly obese patient.

4.     MRI has the greatest specificity of all imaging modalities.

With regard to the management of a pregnant patient with appendicitis,

5.     it should be operative if the diagnosis is certain.

6.     it should primarily aim to reduce any delay in surgical intervention.

7.     it should not involve appendicectomy if the appendix appears normal at the time of surgery.

8.     it should include delivery of the fetus regardless of gestation if the patient is critically ill.

9.     some cases may be treated with antibiotics alone.

General anaesthesia for pregnant women undergoing appendicetomy,

10.   carries ~ a 25-fold increased risk of complications than regional anaesthesia.

11.   has temporary effects on the fetus as all induction and maintenance agents cross the placenta.

12.   has a uterotonic effect.

Surgery for appendicetomy in pregnancy,

13.   increases the rate of miscarriage.

14.   has the lowest risk to the fetus when performed in the second trimester.

15.   should be delayed until antenatal corticosteroids are given (in the absence of severe maternal sepsis) if the gestation is critical.

Concerning acute appendicitis in pregnancy,

16.   it is the most common cause of acute surgical abdomen.

17.   it most commonly occurs in the first trimester.

18.   it has a fetal loss rate exceeding 50% if the appendix perforates.

19.   the primary goal is to rule out differential diagnoses.

20.   the secondary goal is to reduce the negative appendicectomy rate.

45.         Kallmann’s syndrome (Ks).

Scenario 1.                

Which of the following might be included in descriptions of Kallmann’s syndrome?

Option list.

A	hypogonadotrophic hypogonadism
B	hypogonadotrophic hypogonadism + anosmia
C	hypogonadotrophic hypogonadism + anosmia + colour-blindness.
D	hypogonadotrophic hypogonadism due to uterine agenesis

Scenario 2.                

Lead in.

Which, if any, of the following are features of the Kallmann phenotype?

A	absent or minimal breast development
B	aortic stenosis
C	blue eyes
D	blue hair
E	hot flushes
F	short stature
G	tall stature
H	vaginal agenesis
I	none of the above

Scenario 3.                

How common is Kallmann’s syndrome and what is the female: male ratio?

A	1 in 1,000 and F:M ratio 1:1
B	1 in 5,000 and F:M ratio 1:1
C	1 in 10,000 and F:M ratio 1:4
D	1 in 50,000 and F:M ratio 1:4
E	1 in 100,000 and F:M ratio 1:8
F	1 in 250,000 and F:M ration 1:10

Scenario 4.                

What is the most common mode of inheritance of Ks?

Option list.

A	hypogonadotrophic hypogonadism
B	hypogonadotrophic hypogonadism + anosmia
C	hypogonadotrophic hypogonadism due to uterine agenesis
D	autosomal dominant
E	autosomal recessive
F	X-linked recessive
G	new mutation of the ANOS1 gene
H	the most common mode of inheritance is not known

Scenario 5.                

How is Kallmann’s syndrome diagnosed?

A	abdominal and pelvic ultrasound scan
B	cell-free fetal DNA
C	chromosome analysis
D	CT scan of hypothalamus / pituitary
E	MR scan of hypothalamus / pituitary
F	none of the above.

Scenario 6.                

How is Kallmann’s syndrome treated initially?

Which of the following statements are true?

Option list.

A	GnRH analogue depot
B	pulsatile GnRH therapy
C	combined oral contraceptive
D	counselling & education re gender re-assignment
E	depot progestogen
F	none of the above

Scenario 7.                

A woman was diagnosed with Kallmann’s syndrome at 16 and had successful initial treatment. She is now 25, married and wishes to have a pregnancy. She has had pre-pregnancy assessment and counselling. Which of the following can be considered?

A	GnRH analogue depot
B	induction of ovulation with clomiphene
C	gonadotrophin therapy
D	pulsatile GnRH therapy
E	none of the above

46.         Antenatal steroids and the neonate.

Abbreviations.

ANC:     antenatal corticosteroids.

ANS:      antenatal steroids.

NG25:   NICE’s Guideline 25: “Preterm labour and birth”. November 2015.

Lead-in.

The following scenarios relate to antenatal steroid use and the neonate.

There are no option lists and you must decide your answers without help.

Scenario 1.

What are the benefits to the neonate of appropriate administration of antenatal steroids?

Scenario 2.

At what gestations should antenatal steroids be offered to women with singleton pregnancies who are at risk of premature labour?

Scenario 3.

At what gestations should antenatal steroids be offered to women with multiple pregnancies who are at risk of premature labour?

Scenario 4.

What advice is contained in NG25 about ANS and very early gestations?

Scenario 5.

What advice is contained in NG25 GTG about antenatal steroids and Caesarean section?

Scenario 6.

What advice is given in the NG25 about ANS in relation to the fetus with FGR at risk of premature delivery?

Scenario 7

What advice is given in NG25 about ANS for women with IDDM?

Scenario 8

What advice is in the NG25 about adverse effects of ANS on the fetus?

Scenario 9

What advice is in the GTG in relation to short-term maternal adverse effects?

Scenario 10

What contraindications to ANS are cited in NG25?

Scenario 11

What is the recommended drug regime for ANS administration?

Scenario 12.

What is the time-scale for maximum effect of ANS in reducing RDS?

Scenario 13.

When should repeat courses of ANS be given?

Scenario 14.

Who was the great pioneer of antenatal steroids to accelerate lung maturation?

Scenario 15.

Which country was this great pioneer from and which animal did he use for his early research?

Scenario 16.

Why is the story of this pioneer’s work a cautionary tale for O&G?

Scenario 17.

Which international organisation has immortalised his work in its logo?

Scenario 18.

When may antenatal steroids be beneficial to the fetus apart from accelerating lung maturation?

47.      MgSO4 use in O&G.

           Tell the examiner everything you know of relevance about this subject. The examiner will not prompt or assist in any way.

48.      MCQ. TOG questions from 2017.19.1 on MgSO4 use.

           These will be handed out on completion of Question 47.