Role-play.
Difficult
patient. Wants to see the consultant.
|
|
55
|
Structured
conversation. Air travel in pregnancy.
|
56
|
EMQ.
Zika
virus & pregnancy.
|
57
|
EMQ;
APH.
Antepartum haemorrhage.
|
54. Candidate’s instructions.
You are an ST5 and are in
the gynaecology clinic. A patient has been aggressive towards the reception and
nursing staff, insisting that she must see the consultant, not a junior doctor.
She shouted at both the receptionist and the nurses, saying: ‘I want to see the
organ grinder, not the bloody monkey’.
The consultant says that
she has no intention of seeing her and that you need to learn to deal with
difficult patients.
55. Structured conversation. Air travel in pregnancy. .
Candidate’s instructions.
This is a viva station
about air travel & pregnancy. The examiner will ask you 15 questions..
When you have finished a
question, you will not be allowed to return to it as later questions may
indicate the answer. If you return, no marks will be awarded, even for correct
answers.
Question 1.
The RCOG’s Scientific Impact Paper 1 was about air travel and pregnancy.
What was its assessment of the quality of the available evidence on the
subject? There is no option list.
Question 2.
What maternal pregnancy
complications have been linked to ATIP and what is the current thinking about
the risk of their occurrence?
Question
3.
Lead-in
Which of the following statements, if any, are true?.
Option List
A.
|
there is good
evidence that abruption is more common in passengers
|
B.
|
there is good
evidence that abruption is more common in flight attendants
|
C.
|
there is good
evidence that PPROM is more common in passengers
|
D.
|
there is good
evidence that PPROM is more common in flight attendants
|
E.
|
there is good
evidence that miscarriage and FDIU are more common in flight attendants
|
Question 4.
Which conditions are listed in SIP1 as possible
contraindications to ATIP. There
is no option list.
Question 5.
What fetal and neonatal
complications have been linked to ATIP and what is the current thinking about
the risk of their occurrence? There
is no option list.
Question 6.
Lead-in
When a plane has reached cruising altitude, approximately what altitude
does the cabin pressure equate to?
Option List
A.
|
1,000 feet
|
B.
|
3,000 feet
|
C.
|
6,000 feet
|
D.
|
10,000 feet
|
E.
|
20,000 feet
|
Lead-in
Option List
|
A.
|
5%
|
|
B.
|
10%
|
|
C.
|
15%
|
|
D.
|
20%
|
|
E.
|
25%
|
Question 8.
Lead-in
Which of the following conditions are likely to lead to problems as a
result of the reduced oxygen saturation at cruising altitudes?
Option List
A.
|
anaemia: Hb < 9 g/dl
|
B.
|
women with sickle cell
disease
|
C.
|
women with recent
gastro-intestinal tract surgery involving bowel sutures
|
D.
|
women with recent
urinary tract surgery involving sutures to the bladder
|
E.
|
none of the above
|
Question 9.
Lead-in
What is the reduction in a passenger’s blood oxygen saturation at cruising
altitude in a commercial aircraft?
Option List
A.
|
5%
|
B.
|
10%
|
C.
|
15%
|
D.
|
20%
|
E.
|
None of the above
|
Question 10.
Which, if any, of the following statements are true in relation to
humidity?
Option List
A.
|
air drawn into the plane at cruising altitude has low water content
|
B.
|
humidity at cruising
altitude is about 15%
|
C.
|
humidity in most
buildings is about 60%
|
D.
|
low humidity at cruising
altitude predisposes to dehydration and DVT
|
E.
|
low humidity at cruising
altitude may trigger asthmatic attacks
|
Question 11.
What advice would you give an occasional traveller about the risks from
radiation?
Question 12.
What restrictions on gestation are used by most airlines?
Question 13.
What should pregnant women do to reduce the risk of DVT related to air
travel.
Question 14.
What general issues should
be discussed with a pregnant woman planning a flight?
Question 15.
What advice should be given about seat belts?
Air travel
in pregnancy
The following
are considered safe for use in pregnancy:
1. Hepatitis
B vaccine. True / False
2. Ciprofloxacine
True / False
3. Chloroquine
True / False
4. Water
purified with iodides True / False
5. Rabies
vaccine True / False
6. Mefloquine
True / False
The following statements regarding air
travel in pregnancy are true:
7. Thromboprophylaxis
with low molecular weight heparin is recommended for the majority of pregnant
women on long-haul flights True / False
8. Because of
the high radiation exposure to the fetus, women should avoid more than a single
long-haul trip True / False
9. Airlines
consistently decline to carry women beyond 36-weeks’ gestation True / False
10. Women with
a Hb concentration of <8 g/dl should be advised against travelling True / False
The following statements are true:
11. The
majority of commercial airlines carry equipment for neonatal resuscitation True / False
12. Neonates
are automatically covered by their mother's travel insurance policy True / False
13. Pregnant
women should not pass through airport security machines True / False
14. The
children of airhostesses have an increased risk of congenital abnormality True / False
15. Air travel
does not increase the likelihood of premature labour True / False
Regarding malaria in pregnancy,
16. travel to malarial
areas should be avoided as prophylaxis is contraindicated True / False
17. topical
insect repellents are contraindicated in pregnancy True / False
18. pregnant
women are at an increased risk of contracting malaria infection True / False
19. pregnant
women taking proguanil should receive additional folic acid supplements True / False
20. acute
malaria infection is a cause of intrauterine death True / False
56. Zika virus & pregnancy.
Abbreviations.
CVS: Congenital
Zika Virus Syndrome.
VTR: vertical
transmission rate.
Zv: Zika virus.
Question
1.
What kind of virus is Zika?
A
|
DNA
|
B
|
DNA + RNA during intermediate stage
|
C
|
RNA
|
D
|
RNA + DNA during intermediate stage
|
Question
2.
To which family of viruses does
the Zika virus belong?
A
|
adenoviruses
|
B
|
flaviviruses
|
C
|
herpesviruses
|
D
|
orthomyxoviruses
|
E
|
parvoviruses
|
F
|
picornaviruses
|
G
|
retroviruses
|
H
|
togaviruses
|
Question
3.
What other human infections are
caused by viruses from this family? This is not a proper EMQ: there may be more
than one correct answer.
A
|
bubonic plague
|
B
|
chikungunya
|
C
|
chicken pox
|
D
|
common cold
|
E
|
dengue fever
|
F
|
hepatitis C
|
G
|
Japanese encephalitis
|
H
|
malaria
|
I
|
San Francisco encephalitis
|
J
|
St. Louis encephalitis
|
K
|
West Nile virus
|
L
|
Yellow fever
|
Question
4.
When was the first reported
identification of Zika virus infection in an animal and what was the animal?
A
|
1922 in a hippopotamus
|
B
|
1928 is a giraffe
|
C
|
1935 in a macaque monkey
|
D
|
1947 in a Rhesus negative
monkey
|
E
|
1950 in a chimpanzee
|
H
|
none of the above.
|
Question
5.
Why is the virus called “Zika”?
A
|
it was first described as “zoonosis affecting
Intestines, Kidneys and Adrenals”
|
B
|
the animal from which it was first isolated was the
Zika monkey
|
C
|
it was first isolated from a monkey from the Zika area
of Zambia
|
D
|
it was first isolated from a monkey from the Zika forest
in Uganda
|
E
|
it was first identified in the Zika laboratory of the
CDC
|
F
|
it was first identified by Dr Emily Zika, Professor of
Virology, Pretoria, S Africa
|
G
|
‘Zika’ is the Zulu word for ‘small head’ and the
association was 1st. noted in a Zulu baby
|
Question
6.
What is the main reservoir of
the Zika virus?
A
|
anteaters
|
B
|
horses
|
C
|
humans
|
D
|
marmosets
|
E
|
monkeys
|
F
|
parrots
|
G
|
rats
|
Question
7.
How is the Zika virus
transmitted? This is not a true EMQ as there may be > 1 correct answer.
A
|
Aedes aegypti mosquitos
|
B
|
Aedes albopictus: Asian tiger mosquito
|
C
|
Anopheles gambiae mosquitos
|
D
|
Culex pipiens mosquitos
|
E
|
fleas
|
F
|
ticks
|
G
|
worms
|
H
|
none of the above.
|
Question
8.
At what time of day is
transmission of infection most likely?
A
|
afternoon
|
B
|
evening
|
C
|
morning
|
D
|
night
|
E
|
mid-morning and mid-afternoon to dusk
|
F
|
two hours after sunrise
|
G
|
two hours before sunset
|
H
|
two hours after sunset
|
I
|
two hours after sunrise and two hours before sunset
|
J
|
none of the above
|
Question
9.
Where do aegypti mosquitoes
breed?
Which, if any of the following
A
|
in large stretches of water with reed beds
|
B
|
in water near human habitation
|
C
|
in water remote from human habitation
|
D
|
in water in human habitations
|
E
|
in water with volume > 5 litres
|
F
|
in water with volume > 50 litres
|
G
|
in water with volume > 500 litres
|
H
|
none of the above.
|
Question
10.
When did the current interest
in the Zika virus and pregnancy begin and why?
A
|
Brazil reported an ↑
in microcephaly with a possible link to maternal Zika infection in 2014
|
B
|
Brazil reported an ↑
in microcephaly with a possible link to maternal Zika infection in 2015
|
C
|
Brazil reported an ↑
in microcephaly with a possible link to maternal Zika infection in 2016
|
D
|
the CDC reported 3 cases of microcephaly after proven
Zika infection in pregnancy in 2014
|
E
|
the CDC reported 3 cases of microcephaly after proven
Zika infection in pregnancy in 2015
|
F
|
the CDC reported 3 cases of microcephaly after proven
Zika infection in pregnancy in 2016
|
H
|
none of the above
|
Question
11.
How did the WHO categorise the problem
and when?
A
|
Public Health Emergency of International Concern 2015
|
B
|
Public Health Emergency of International Concern 2016
|
C
|
Public Health Emergency of International Concern 2017
|
D
|
Public Health Emergency of International Concern 2018
|
E
|
none of the above
|
Question
12.
Is Zika virus infection a
notifiable condition in the UK?
A
|
No
|
B
|
Yes, but only if people have returned from an area with
a high prevalence of Zika
|
C
|
Yes, but only if the woman and her partner have
returned from an area with high prevalence of Zika
|
D
|
Yes, but only if fetal damage has occurred.
|
E
|
none of the above
|
Question
13.
How is the risk of getting a
Zika virus infection from travelling to a particular country categorised?
Which, if any, of the following feature?
A
|
frightful
|
B
|
high
|
C
|
low
|
D
|
moderate
|
E
|
scary
|
F
|
none of the above
|
Question
14.
How long does it take for
symptoms of Zika infection to develop?
A
|
1 – 5 days
|
B
|
1 – 7 days
|
C
|
2 – 5 days
|
D
|
2 – 7 days
|
E
|
2 – 10 days
|
F
|
3 – 7 days
|
G
|
3 – 12 days
|
H
|
5 – 10 days
|
Question
15.
How long do symptoms of Zika
infection last?
A
|
1 – 5 days
|
B
|
1 – 7 days
|
C
|
2 – 5 days
|
D
|
2 – 7 days
|
E
|
2 – 10 days
|
F
|
3 – 7 days
|
G
|
3 – 12 days
|
H
|
5 – 10 days
|
Question
16.
What are the most common
symptoms of Zika infection? There is no option list – write what you think.
Question
17.
Is Zika infection more severe
in pregnancy?
A
|
No
|
B
|
Yes
|
Question
18.
What abnormalities have been
associated with Congenital Zika Virus Syndrome? There is no option list, just
write as many as you can think of.
Question
19.
What is thought to be the
significance of head circumference at birth in babies whose Hc is in the normal
range?
A
|
higher Hc is associated with ↓ cognitive
scores
|
B
|
higher Hc is associated with ↓ language scores
|
C
|
lower Hc is associated with ↓ cognitive
scores
|
D
|
lower Hc is associated with ↓ language
scores
|
E
|
Hc is of no significance
|
F
|
there is no information on this subject
|
Question
20.
What is the approximate risk of
vertical transmission of the Zika virus in pregnancy?
A
|
10%
|
B
|
20%
|
C
|
30%
|
D
|
40%
|
E
|
≥ 50%
|
E
|
the figure is unknown
|
Question
21.
Is gestation related to the
risk of vertical transmission of the Zika virus? Which, if any, of the following
statements are true?
A
|
evidence is unclear
|
B
|
evidence suggests it probably is
|
C
|
evidence suggests it probably is not
|
D
|
no
|
E
|
yes
|
Question
22.
What is the risk of adverse
fetal outcomes for women proven to have had Zika virus infection?
A
|
~ 5%
|
B
|
~ 10%
|
C
|
~ 15%
|
D
|
~ 20%
|
E
|
~ 25%
|
F
|
~30%
|
G
|
> 30%
|
H
|
none of the above
|
Question
23.
What advice should be given to
a pregnant woman planning to travel to an area with high risk of transmission
of Zika infection?
A
|
consider postponing travel until after the pregnancy
|
B
|
don’t go to the area
|
C
|
get vaccinated
|
D
|
stay indoors from dawn to dusk
|
E
|
take chloroquine as prophylaxis
|
F
|
take chloroquine + proguanil as prophylaxis
|
G
|
take proguanil as prophylaxis
|
Question
24.
What advice should be given to
a pregnant woman planning to travel to an area with moderate risk of
transmission of Zika infection?
A
|
consider postponing travel until after the pregnancy
|
B
|
don’t go to the area
|
C
|
get vaccinated
|
D
|
stay indoors from dawn to dusk
|
E
|
take chloroquine as prophylaxis
|
F
|
take chloroquine + proguanil as prophylaxis
|
G
|
take proguanil as prophylaxis
|
Question
25.
What advice should be given to
a woman who decides to travel to an area of high or moderate risk?
There is no option list: jot
down everything you think would be relevant.
Question
26.
A woman returns to the UK from
a high-risk Zika area? She develops symptoms suggestive of Zika infection 4
weeks later. What testing should be offered?
A
|
abdominal ultrasound
|
B
|
amniocentesis
|
C
|
MR scan
|
D
|
no test indicated
|
E
|
TVS
|
F
|
Zika IgA
|
G
|
Zika IgG
|
H
|
Zika IgG + IgM
|
I
|
Zika IgA + IgG + IgM
|
J
|
Zika PCR
|
Question
27.
A woman who wishes to be
pregnant has returned to the UK from an area of high-risk for Zika infection.
Her partner had remained in the UK? What advice should she be given?
A
|
use barrier contraception for 8 weeks
|
B
|
use effective contraception for 8 weeks
|
C
|
use barrier contraception + effective contraception for
8 weeks
|
D
|
use barrier contraception for 12 weeks
|
E
|
use effective contraception for 12 weeks
|
F
|
use barrier contraception + effective contraception for
12 weeks
|
Question
28.
A man travels to an area with
high-risk of Zika infection? On his return to the UK his wife is keen to start
a pregnancy. What advice should be given?
A
|
use barrier contraception for 8 weeks
|
B
|
use effective contraception for 8 weeks
|
C
|
use effective contraception + barrier contraception for
8 weeks
|
D
|
use barrier contraception for 12 weeks
|
E
|
use effective contraception for 12 weeks
|
F
|
use effective contraception + barrier contraception for
12 weeks
|
G
|
use barrier contraception for 6 months
|
H
|
use effective contraception for 6 months
|
I
|
use effective contraception + barrier contraception for
6 months
|
J
|
none of the above.
|
Question
29.
A man travels to an area with
high-risk of Zika infection for two weeks? During his stay he has symptoms
suggestive of Zika infection. His wife is pregnant. What testing should be
offered on his return?
A
|
discuss with local infection specialist
|
B
|
discuss with RIPL
|
C
|
no test indicated
|
D
|
Zika IgG
|
E
|
Zika IgG + IgM
|
F
|
Zika IgA + IgG + IgM
|
G
|
Zika PCR
|
H
|
none of the above
|
Question
30.
A woman is shown to have had a
Zika infection? How useful is amniocentesis for assessing the risk to the fetus
and determining if an infected fetus in affected?
A
|
PCR on amniocentesis is the gold standard for
diagnosing fetal infection
|
B
|
PCR on amniocentesis is of unknown value for diagnosing
fetal infection
|
C
|
PCR on amniocentesis is of little value for diagnosing
fetal infection
|
D
|
PCR on amniocentesis is the gold standard for determining
the risk of an infected fetus being affected
|
E
|
PCR on amniocentesis is of unknown value for
determining the risk of an infected fetus being affected
|
F
|
PCR on amniocentesis is of little value for diagnosing
fetal infection
|
Question
31.
What advice and treatment
should be offered to the non-pregnant individual with symptoms of Zika
infection? This is not a true EMQ as more than one option could be true.
A
|
adequate fluids
|
B
|
acyclovir from GP
|
C
|
bed rest for 48 hours
|
D
|
emergency contraception
|
E
|
get advice from A&E centre
|
F
|
offer TOP
|
G
|
paracetamol if needed for pain
|
Question
32.
A pregnant woman returns from a
high-risk Zika area and develops symptoms suggestive of infection? She develops
a high fever and is admitted to hospital. What particular things should be
done?
A
|
anticoagulant prophylaxis
|
B
|
paracetamol + tepid sponging
|
C
|
exclude chikungunya
|
D
|
exclude dengue
|
E
|
exclude malaria
|
F
|
exclude UTI
|
G
|
exclude Zika
|
H
|
exclude other causes of pyrexial illness
|
I
|
offer TOP
|
J
|
none of the above
|
A pregnant woman returns from a high-risk Zika area and
develops symptoms suggestive of infection? She develops a high fever and is
admitted to hospital. What should be
done in relation to NSAIDs?
A
|
they should not
be used
|
B
|
they should not
be considered until dengue has been ruled out
|
C
|
they should not
be considered until malaria has been ruled out
|
D
|
the risk of
premature closure of the ductus arteriosus rules out their use
|
E
|
none of the
above.
|
Question
34.
A woman with possible Zika
exposure has a –ve test for virus antibodies 4 weeks after the last possible
exposure. Is this sufficiently long to reassure her that she has not been
infected?
A
|
no
|
B
|
yes
|
C
|
we don’t know
|
Question
35.
A pregnant woman has visited a
country with high-risk for Zika exposure but been asymptomatic during her stay
and for two weeks on her return? What testing should be offered?
A
|
baseline ultrasound + repeat at 18-20 weeks
|
B
|
baseline ultrasound + repeat at 28-30 weeks
|
C
|
baseline ultrasound + repeat at 18-20 weeks + consider
repeat at 28-30 weeks
|
D
|
amniocentesis
|
E
|
MR scan
|
F
|
no test indicated
|
G
|
Zika IgG
|
H
|
Zika IgG + IgM
|
I
|
Zika IgA + IgG + IgM
|
J
|
Zika PCR
|
Question
36.
A pregnant woman returns to the
UK from an area of high risk for Zika exposure has normal ultrasound scans on
her return and at 22 weeks. What further scans, if any, should be arranged?
This question is in the exam database.
A
|
monthly scans
|
B
|
scan at 28-30 weeks
|
C
|
scan at 32 and 36 weeks
|
D
|
scan at 36 weeks
|
E
|
no further scans
|
F
|
none of the above
|
Question
37.
A pregnant woman with possible Zika
exposure has an ultrasound scan showing the fetal BPD to be > 2 SDs below
the mean for that gestation. What should be done?
A
|
discuss amniocentesis to confirm fetal infection
|
B
|
discuss with the local virologist
|
C
|
offer TOP
|
D
|
refer to a fetal medicine specialist
|
E
|
screen the mother for recent Zika infection
|
F
|
none of the above
|
Question
38.
A pregnant woman with possible
Zika exposure has an ultrasound scan showing significant brain abnormality.
What further testing should be discussed?
A
|
amniocentesis + PCR
|
B
|
amniocentesis + RT-PCR
|
C
|
MR scan
|
D
|
Zika IgG
|
E
|
Zika IgG + IgM
|
F
|
Zika IgA + IgG + IgM
|
G
|
none of the above
|
57. Antepartum haemorrhage.
Abbreviations.
ART: assisted reproduction technology
FGR: fetal growth restriction
PET: pre-eclampsia
Option list.
A.
genital tract bleeding ≥ 500 ml. from 24 weeks
until the delivery of the baby
B.
genital tract bleeding ≥ 500 ml. from 24 weeks
until the delivery of the placenta.
C.
genital tract bleeding ≥ 500 ml. from 24 weeks,
or earlier if the baby is live-born, until the delivery of the baby.
D.
1
E.
2
F.
3
G.
4
H.
5
I.
6
J.
7
K.
8
L.
9
M.
10
N.
15
O.
20
P.
30
Q.
50
R.
100
S.
500
T.
1,000
U.
true
V.
false
W.
none of the above
Scenario 1.
What is the definition of APH?
Scenario 2.
What is the upper limit in ml.
for minor APH
Scenario 3.
What is the upper limit in ml.
of major haemorrhage
Scenario 4.
What is the % risk of recurrence after 1 abruption?
Scenario 5.
What is the % risk of recurrence after 2 abruptions?
Scenario 6.
What is the major risk factor
for placental abruption?
Scenario 7
List 10 risk factors for
placental abruption.
Scenario 8
List 6 risk factors for
placenta previa.
Scenario 9
In what % of pregnancies does
APH occur?
Scenario 10
With regards to steps that can be taken to reduce the
incidence of APH, what things would you include in a ‘structured conversation’
in the Part 3 exam?
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