Tutorial 30th. April 2020

Contact us

Website

8	EMQ. Hepatitis B.
9	Role-play. Breaking bad news. Non-viable early pregnancy.
10	Role-play. Anencephaly.
11	Structured discussion. Breastfeeding.

Role-players.

Beatrice and Harriet Lamb.

Active participants.

Parul Aggarwal

Ananya Basu

Purnima Dalal.

Fiona Mackie

Poornima Narendra

8.     EMQ. Hepatitis B.

Topic. Hepatitis B and pregnancy.

Lead-in.

These scenarios relate to hepatitis and pregnancy.

Instructions.

For each scenario, select the most appropriate option from the option list.

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

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

Question 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?

Question 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?

Question 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?

Question 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?

Question 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?

Question 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?

Question 7.          

How common is chronic HBV carrier status in UK pregnant women?

Question 8.          

What is the risk of death from chronic HBV carrier status?

Question 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?

Question 10.      

A woman is a known carrier of HBV. What is the risk of vertical transmission in the first trimester?

Question 11.      

What is the risk of the neonate who has been infected by vertical transmission becoming a carrier without treatment?

Question 12.      

Should antiviral maternal therapy in the 3^rd. trimester be considered for women with HBeAg or high viral load?

Question 13.      

How effective is hepatitis B prophylaxis for the neonate in preventing chronic carrier status as a result of vertical transmission?

Question 14.      

Can a woman who is a chronic HBV carrier breastfeed safely?

Question 15.      

Hepatitis B infection is the most dangerous of the viral hepatitis infections in pregnancy.

Question 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?

Question 17.      

How long can HBV survive outside the body?

Option list.

A	< 1 hour
B	up to 6 hours
C	up to 12 hours
D	up to 24 hours
E	up to 2 days
F	up to 5 days
G	at least 7 days

Question 18.      

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?

Question 19.      

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!

Question 20.      

What does 5 log10 copies /mL mean?

A	> 10 copies / mL
B	> 100 copies / mL
C	> 1,000 copies / mL
D	> 10,000 copies / mL
E	> 100,000 copies / mL
F	this has scared me witless and I am going straight home to complain to my Mum

Question 21.      

Which, if any, of the following statements are true about amniocentesis and CVS and the risk of vertical transmission if the mother is HbsAg+ve?

Option list.

A	they are contraindicated
B	they should be done with cover with HBIG
C	they should be done with cover with a drug that is  effective for HBV and safe in pregnancy.
D	none of the above

Question 22.      

Which, if any, of the following statements are true about treatment in the third trimester to reduce the risk of vertical transmission?

Option list.

A	women who are HbsAg+ve should be offered testing for HBV DNA levels in the 3rd. trimester
B	there is no effective treatment for HBV in the 3rd. trimester
C	the risks of treatment for HBV in the 3rd. trimester outweight the benefits
D	drug treatment for HBV in the 3rd. trimester adds nothing beneficial  to the normal use of HBIG + HB vaccination of the neonate
E	none of the above.

Question 23.      

Which, if any, of the following drugs is recommended for use in the third trimester to reduce the risk of vertical transmission?

Option list.

A	acyclovir
B	lamivudine
C	telbivudine
D	tenofovir

Question 24.      

Does elective Cs before labour and with the membranes intact reduce the vertical transmission rate?

Question 25.      

Which hepatitis virus normally produces a mild illness, but represents a major risk to pregnant women, with a mortality rate of up to 5%?

Question 26.      

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?

Question 27.      

Which hepatitis virus is an absolute contraindication to breastfeeding after appropriate treatment of the infected mother and prophylaxis for the baby?

Question 28.      

Which hepatitis virus is linked to an increased risk of obstetric cholestasis?

9.     Breaking bad news: non-viable early pregnancy

Candidate’s instructions.

You are the SpR in the ante-natal clinic. The Consultant who was in clinic has been asked to assist her Consultant colleague in the labour ward theatre. She is unlikely to return for some time as the case is one of massive PPH and hysterectomy may be necessary. 

One of the midwives asks you to see a patient who has just had a scan in the EPU.  She is primigravid and the gestation is 8 weeks. She has had some bleeding.   

An ultrasound scan = IUP.  CRL = 12 mm.  No fetal heart activity.  No adnexal masses.

Your instructions are to deal with the patient as you would in clinic.

10. Anencephaly.

Candidate’s instructions.

You are an SpR5 and running the ante-natal clinic – your consultant has been called to help a consultant colleague with an emergency on the labour unit and is not available for advice.

You are about to see Jean Hathersage. She is 25 years old and had a 10-week scan last week that showed anencephaly. She stated that she did not want TOP. She was counselled, given information leaflets and asked to return to the antenatal clinical today for further discussion. Your task is to conduct that discussion.

11.  Structured discussion. Breastfeeding    

Candidate’s instructions.

This is a viva station about breastfeeding.

The examiner will ask you 7 questions.