23rd. July 2020

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58	Role-play. Teach FY1 about complaint procedures.
59	Structured conversation. Bacterial vaginosis.
60	SBA. Appendicitis in pregnancy.
61	SBA. CAESAR trial.
62	SBA. Endometrial cancer and obesity.

58. Complaint procedures.

Candidate’s instructions.

You are a 5^th. year SpR. The consultant responsible for risk management has asked you to teach a new O&G trainee about complaints.

59. Structured conversation. Bacterial vaginosis.

The examiner will ask you 22 questions about BV.

60. Appendicitis in pregnancy.

Abbreviations.

AIP:                    appendicitis in pregnancy

CRP :                  C reactive protein

EFHRM:            electronic fetal heart rate monitoring

RLQP:                right lower quadrant pain

RUQP:               right upper quadrant pain

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

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

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

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

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

How useful is the finding of leucocytosis in making the diagnosis of AIP?

Option List

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

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. These are open access, so are reproduced here.

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.

61. The “CAESAR” trial

Abbreviations.

ECV:     external cephalic version

Question 1.

Lead-in

What was the CAESAR trial?

Which, if any, of the following statements are true?

Statements

A	a prospective, cohort study
B	a randomised, controlled trial
C	a comparison of selected techniques used during C section
D	a study of the risks of C section on maternal request without medical grounds
E	a study of the outcomes of C section performed after failed instrumental delivery

Option List

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

Question 2.

Lead-in

Where did the questions addressed by the trial come from?

Option list

A	the RCOG council
B	the RCOG exam committee
C	a survey of UK obstetricians asking what questions they would like to have answered
D	Dr. Johnstone, Consultant Obstetrician, Falkirk
E	National Childbirth Trust

Question 3.

Lead-in

The questionnaire also asked about the issues that the respondents would like to see addressed in a research programme. What issues were included in the CAESAR trial?

Statements

A	outcome of C. section depending on aqueous versus alcohol-based skin preparation
B	outcomes of cord traction versus manual removal of the placenta
C	outcomes of digital versus ‘swab on a holder’ exploration of the uterine cavity to exclude RPOC
D	outcomes of Joel-Cohen compared with Pfannenstiel incision
E	outcome of elective C. section at 38 versus 39 weeks
F	outcome of elective C. section with staff wearing masks versus not wearing masks
G	outcome of prophylactic antibiotics versus no prophylactic antibiotics
H	outcome of pre-op vaginal antiseptic “painting”
I	outcome of blunt v. sharp opening of the lower segment
J	outcomes of manual versus forceps delivery of the fetal head in cephalic presentations
K	outcome of single v double closure of the lower segment
L	outcome of closure v non-closure of parietal & pelvic peritoneum
M	outcome of liberal v restricted use of pelvic drains
N	outcome of glue v subcuticular suturing of the skin
O	none of the above

Option List

1	A + B + C + D + E + F + G + H + I + J + K+ L + M + N + O
2	D + F + G + H + K+ L
3	G + H + K+ L + M
4	K + M
5	O

Question 4.

Lead-in

Which of the following statements is true of the definition of the 1ry. outcome?

Option list

A	use of antibiotics for maternal infectious morbidity during the hospital stay
B	use of antibiotics for maternal infectious morbidity during the 1st. six weeks
C	duration of postnatal hospital stay
D	abdominal and pelvic pain as measured on an analogue scale at 6 weeks
E	none of the above.

Question 5.

Lead-in

Which, if any, of the following describe the 2ry. outcomes?

Statements

A	additional treatments to the abdominal wound
B	haematoma formation
C	pain
D	breast feeding at discharge
E	breast feeding at 6 weeks
F	unexpected maternal morbidity
G	postnatal depression at 6 weeks
H	puerperal psychosis

Option List

1	A + C
2	A + D
3	B + C
4	B + D
5	B + E
6	none of the above

Question 6.

Lead-in

Which if any of the following statements are true of the findings of the study?

Statements

A	there were no significant differences for any outcome
B	there was more endometritis after non-closure of the pelvic peritoneum
C	there was more 2ry. bleeding after interrupted-suture closure of the lower segment
D	there was more evidence of pelvic infection with liberal use of pelvic drains
E	none of the above.

62. Endometrial cancer & obesity.

Question 1.

Lead-in

What % of endometrial cancer is attributed to obesity?

Option List

F.	5%
G.	15%
H.	20%
I.	30%
J.	50%

Question. 2

Lead-in

What is the incidence of endometrial cancer compared with other female cancers?

Option List

F.	It is the most common.
G.	It is the second most common.
H.	It is the fourth most common.
I.	It is the tenth most common.
J.	It is the fifteenth most common.

Question 3.

Lead-in

Where does endometrial cancer appear in the list of cancers causing female deaths in the UK?

Option List

A.	It is the most common.
B.	It is the second most common.
C.	It is the fourth most common.
D.	It is the ninth most common.
E.	It is the fifteenth most common.

Question 4.

Lead-in

What proportion of the female population of the UK is obese?

Option List

F.	10%
G.	15%
H.	25%
I.	30%
J.	40%

Question 5.

Lead-in

Which option is correct in relation to the type of endometrial cancer associated with obesity?

       i.           type 1.

      ii.           type 2.

    iii.           type 3.

    iv.           adeno-squamous

Option List

A.	i
B.	ii
C.	iii
D.	iv
E.	i + iv

Question 6.

Lead-in

Pick the correct option from the option list in relation to the following statements.

Statements

       i.           the risk of EC increases significantly with BMI > 25

      ii.           the risk of EC increases significantly with BMI > 30

    iii.           the risk of EC increases significantly with BMI > 35

    iv.           the risk of EC increases significantly with BMI > 40

      v.           the risk of EC increases significantly with BMI > 45

Option List

A.	i
B.	ii
C.	iii
D.	iv
E.	v

Question 7.

Lead-in

Which of the following statements is correct?

Statements

       i.           the risk of EC rises linearly in relation to increasing BMI

      ii.           the risk of EC rises exponentially in relation to increasing BMI.

    iii.           the risk of EC rises according to the following formula:

R = 0.7 x BMI x Y. Where R = lifetime risk, Y = duration of significant BMI in years.

    iv.           the risk of EC doubles with BMI> 30 and trebles with BMI > 40

      v.           the risk of EC in relation of obesity has not been defined

Option List

E.	i
F.	ii
G.	iii
H.	iv
I.	v

Question 8.

Lead-in

Which, if any, of the following statements are true?

Statements

       i.           the incidence of endometrial cancer increased by 20% between 1975 and 1993

      ii.           the incidence of endometrial cancer increased by 20% between 1993 and 2007

    iii.           the incidence of endometrial cancer increased by 40% between 1993 and 2007

    iv.           the greatest increase in EC has been in the 50 - ≥60 years age band

      v.           the greatest increase in EC has been in the 60 - 79 years age band

Option List

A.	i + ii
B.	i + iii
C.	i + iv
D.	ii + iv
E.	iii + v

Question 9.

Lead-in

Which of the following best indicates current overall 5-year survival rates for women treated for EC.

Option List

A.	55%
B.	60%
C.	65%
D.	70%
E.	75%

Question 10.

Lead-in

The surgical technique of choice for EC is:

Option List

A.	Abdominal hysterectomy + BSO
B.	Abdominal hysterectomy + BSO + lymphadenectomy
C.	Laparoscopic hysterectomy + BSO
D.	Laparoscopic hysterectomy + BSO + lymphadenectomy
E.	Vaginal hysterectomy + BSO

Question 11.

Lead-in

Which, if any, of the following statements are true in relation to laparoscopic hysterectomy + BSO by experienced laparoscopic surgeons compared to open hysterectomy + BSO in obese women with EC?

Statements.

i.	Rates of conversion to laparotomy are likely to exceed 50%
ii.	Intra-operative complication rates are roughly doubled
iii.	Duration of hospital stay and early complications are reduced
iv.	Patient-reported outcomes at 6 months are superior.
v.	5-year survival rates are superior

Option List

A.	i + ii
B.	i + iii
C.	iii
D.	iii + iv
E.	iv + v

Question 12.

Lead-in

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

Option List

A.	radiotherapy should be recommended if there are significant co-morbidities
B.	external beam radiotherapy is the recommended modality
C.	brachytherapy is the recommended modality
D.	recurrence rates of up to 18% have been reported
E.	none of the above

Question 13.

Lead-in

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

Option List

A.	high-dose progestogen therapy from the time of the initial endometrial biopsy to definitive surgery improves 5-year survival
B.	the 52 mg IUS is of proven efficacy and safety for women with endometrial hyperplasia with cytological atypia who wish to retain their fertility
C.	the 52 mg IUS is of proven efficacy and safety for women with endometrial hyperplasia with early endometrial cancer
D.	high-dose progestogen therapy is effective in palliative care in 50%  of cases in reducing tumour size and bleeding
E.	none of the above