MRCOGManchester: October 2020

Monday 26 October 2020

Tutorial 26th. October 2020

107	Role-play. Androgen insensitivity syndrome.
108	Role-play. Fetal death in utero. FDIU.

107. Androgen insensitivity syndrome.

Candidate's Instructions.

The patient is Anastasia Johnstone. She is 17 years old. She attended the gynaecology clinic 1 month ago with primary amenorrhoea. Clinical examination showed an apparently normal young woman with normal breast development but absent pubic and axillary hair. The external genitalia appeared normal. Vaginal examination was not attempted.

She has come today for the results of an ultrasound scan and blood tests. The scan shows absence of the uterus. There are no ovaries in the pelvis. There are bilateral groin masses. The karyotype is 46XY.

Your tasks are to explain the results and their implications and to answer her questions.

108. Role-play. Fetal death in utero. FDIU.

Candidate’s instructions.

You are an SpR and were successful in a consultant interview last week. You are now working your notice period before taking up your new post, which has a particular component in labour ward management.

Anne West is a 25-year-old primigravida who delivered a stillborn baby in the night. Her husband works in Saudi Arabia and won’t be able to get home until tomorrow. She has opted to stay in hospital until then. The pregnancy was normal. She noted reduced fetal movements the day before yesterday. There were no movements when she awoke, so she phoned the labour ward and was advised to attend. Fetal heart activity could not be detected and an ultrasound scan confirmed fetal death in utero. A detailed scan was not done because of her distress, but no gross abnormality was seen and the liquor volume looked reduced but in the normal range. The cervix was noted to be effaced and 2 cm. dilated. She opted to have labour induced immediately and arranged for her sister to be with her as her husband works overseas. The labour was normal, as was the delivery.

Your consultant has said that it will be good experience to take responsibility for talking to her about bereavement and permission for post-mortem examination.

Thursday 22 October 2020

Tutorial 22nd October 2020

Website

104	Julie Morris. How to critique a paper
105	Discussion. Plan an agenda for the next station.
106	Role-play. BRCA1 carrier. Risk reduction.

104. Julie Morris. How to critique a paper.

This has come in OSCE exams, though usually with a preparatory station. Some new variant may be created for the Part 3 and a good technique for rapid assessment of a paper will be essential..

105. Discussion. Plan an agenda for the next station. .

There was a recent paper in the BJOG by Gaba et al about the attitudes of women who are BRCA carriers to risk-reducing surgery. It is open access, so I have added it to the papers for today’s tutorial on Dropbox. You can also download it from the internet.

https://obgyn.onlinelibrary.wiley.com/doi/full/10.1111/1471-0528.16424.

When I read it, I realised that it would have triggered me to write a station for the exam had I been an examiner and would also be a good basis for an exercise in creating an agenda for a station. How are you going to really impress an examiner?

106. Role-play. BRCA1 carrier. Risk reduction..

This is the logical follow-on – put the above agenda into action.

Candidate’s instructions.

You are an SpR5 in the gynaecology clinic and about to see Jessica Green. DOB 1 January 1990.

Your tasks are to take an appropriate history and discuss the options available to her.

GP letter.

The Surgery,

Main Road,

Anytown.

Re: Jessica Green, 25 Blether Alley, Anytown.

Dear Gynaecologist,

Please see this charming young lady.

Dr. Rosemary Ique, my very clever young colleague, saw her last year to discuss management of anaemia and heavy periods. There was good response to the use of a Mirena and some iron pills, but clever Dr. Rosemary elicited a family history of cancer and referred her to the regional Familial Genetic Cancer clinic and it turns out that she is a carrier of an oncogenic BRCA mutation. All of this is quite new to me, I must say, and I suspect that I might not have sparked to the importance of the family history, or even uncovered it! There was some discussion of her options to reduce her risk of cancer and she would very much like to explore these further.

I look forward to hearing your thoughts.

Dr. John Worthy.

Monday 19 October 2020

Tutorial 19th. October

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99	EMQ. Leflunomide.
100	Role-play. Borderline ovarian tumour.
101	Role-play. Laparoscopy bowel injury.
102	Viva. FDA warning re NSAIDs
103	EMQ. Ulipristal.

99. EMQ. Leflunomide.

Question 1.

What kind of drug is Leflunomide?

Option list.

A	antibiotic
B	antiemetic
C	cytotoxic drug related to methotrexate
D	non-steroidal anti-inflammatory drug
E	disease-modifying anti-rheumatic drug
F	disease-modifying anti-leprosy drug
G	none of the above

Question 2.

Why is leflunomide of particular interest to O&G specialists?

This is not a true EMQ as there may be more than one correct answer.

Option list.

A	it is a proven human teratogen
B	women must avoid pregnancy for at least 6 months after stopping treatment
C	women require a ‘washout’ with cholestyramine or activated charcoal before conception
D	it is anti-oestrogenic and impairs the efficacy of the combined oral contraceptive
E	it is anti-progestogenic and impairs the progestogen-based contraception, including the Mirena
F	it increases the risk of gestational diabetes mellitus
G	it is an inhibitor of pyrimidine synthesis
H	none of the above.

Question 3.

Who may prescribe leflunomide?

Option list.

A	any doctor who has checked the BNF
B	General Practitioners, but only those who are MRCGP- qualified
C	only maternal-fetal-medicine specialists
D	only specialists in family planning
E	only specialists in the management of diabetes
F	only specialists in the management of leprosy
G	only specialists in the management of rheumatoid arthritis

Question 4.

What monitoring should be done for those taking leflunomide?

Option list.

A	assay of alanine aminotransferase (ALT)
B	assay of gamma-glutamyl transferase (GGT)
C	assay of glutamo-pyruvate transferase (GPT)
D	full blood count (FBC)
E	glucose tolerance
F	renal function
G	respiratory function
H	none of the above

100. Role-play. Borderline ovarian tumour.

Candidate’s instructions.

You are an SpR5 in the gynaecology clinic. Marge Morris had emergency laparotomy for a twisted ovarian cyst 6 weeks ago and has attended for follow-up.

The histology report is of a borderline tumour. The operation notes indicate that the ovary and Fallopian tube were removed and that the other ovary and tube looked normal.

You consultant has told you that it will be good experience for you to discuss the implications of the surgery and the histology report with Marge.

101. Role-play. Bowel injury at laparoscopy.

Candidate’s instructions.

You performed a laparoscopy earlier on Mary White as investigation of 1ry. infertility. As soon as you started to insert the laparoscope, you realised that the trochar had entered the bowel. You left the trochar in situ and asked your consultant and the consultant in general surgery to attend. The surgeon performed laparotomy and repaired the bowel. There was no injury other than the damage from the trochar. The surgeon advised that the prognosis should be good. Laparoscopy showed no gynaecological abnormality but tubal patency tests were not done for fear that it might increase the risk of infection.

It is now 4 hours since the operation. Mary has asked why she has not been allowed to go home. Her sister has come to collect her. The patient is still feeling drowsy and has some pain, so has asked her sister to find out what happened, when she can go home and what it means for her fertility.

Your consultant has said that you have to learn to deal with difficult situations and told you to get on with it.

102. Viva. FDA warning re NSAIDs

Candidate’s instructions.

This is a structured viva. The examiner will ask three questions.

103. EMQ. Ulipristal.

Option list.

A	GnRH analogue.
B	Selective serotonin reuptake inhibitor.
C	19-nortestosterone derived progestogen.
D	21-hydroxyprogesterone-derived progestogen.
E	mifepristone derivative.
F	Selective oestrogen receptor modulator.
G	Selective progesterone receptor modulator.
H	Urinary excretion.
I	Metabolised by renal cytochrome P450 enzyme system.
J	Metabolised by hepatic cytochrome P450 enzyme system.
K	30 mg. with dose repeated if vomiting occurs within 3 hours.
L	100 mg. with dose repeated if vomiting occurs within 3 hours.
M	150 mg. with dose repeated if vomiting occurs within 3 hours.
N	phenobarbitone
O	valium
P	erythromycin
Q	12 hours.
R	18 hours.
S	32 hours.
T	72 hours.
U	120 hours.
V	Depot-contraception.
W	Depression.
X	Emergency contraception.
Y	Menorrhagia.
Z	Termination of pregnancy.
AA	Yes.
AB	No.
AC	Maybe.
AD	Continue.
AE	Discontinue for 36 hours.
AF	Discontinue for 72 hours.
AG	May interfere with contraception containing progestogen.
AH	May interfere with contraception containing oestrogen.
AI	No action if LARC being used.

Scenario 1.

What type of drug is ulipristal?

Scenario 2.

How is ulipristal broken down / excreted?

Scenario 3.

What is the half-life of ulipristal?

Scenario 4.

Which drug (erythromycin, phenobarbitone, Valium) may prolong the half-life of ulipristal?

Scenario 5.

What is the main use of ulipristal?

Scenario 6.

What is the dose of ulipristal?

Scenario 7.

What time-scale applies to the licensed use of ulipristal?

Scenario 8.

What contraceptive advice is given to those using ulipristal?

Scenario 9.

What advice is given to women who are breast-feeding?

Scenario 10.

Can treatment with ulipristal be repeated within 1 month?

Scenario 11.

Which medical conditions are contraindications to ullipristal use ? – these are not on the option list.

Scenario 12.

What is the situation re prescribing ulipristal?

Thursday 15 October 2020

Tutorial 15 October 2020

Website

96	Role-play. Previous SB. ↑ BP. IUGR. Complaint.
97	Viva. Asymptomatic bacteriuria and pregnancy
98	Role-play. Transgender. Menorrhagia. Emily, Rob

96. Role-play. Previous SB. ↑ BP. IUGR. Complaint.

Candidate’s instructions.

You are a year 5 SpR. Andrea Mather has booked for care in her second pregnancy. Her first baby was stillborn at 39 weeks. The midwife who did the booking has asked you to see her to discuss the implications for this pregnancy. Dr. Reid, the consultant, has said that you need to learn how to deal with difficult situations, but to discuss your proposed management with her before the patient leaves the clinic.

GP referral letter.

Please see Andrea Mather who is pregnant for the 2^nd. time, LMP 26^th. June. Dr. Jones, a young colleague, who has a particular interest in obstetrics and is a member of the RCOG, scanned her today and the pregnancy is viable, looks normal and the gestation fits with the LMP.

Sadly, Andrea’s first pregnancy ended disastrously: the baby was stillborn. Andrea and her family have concerns about the care she received at the hospital and believe that she should make a formal complaint. I have spoken to Dr. Reid by phone to alert her to this sensitive issue. The problem is that Andrea was referred by Sister Williams, our midwife, at 38 weeks with hypertension and an impression of IUGR. Andrea says that no investigation was done, not even a scan. She was discharged and told to see Sister Williams a week later. Sister Williams had the nasty experience at that appointment of having to inform Anrea that fetal heart activity could not be detected. Dr. Jones was not available to scan her, but a scan at the hospital confirmed FDIU. The baby only weighed 3 lb. I had a letter from a Dr. Reynold’s after Andrea’s follow up visit six weeks later. He indicated that he was a SpR. The letter was very brief and only stated that no explanation was found. I presume that some kind of perinatal review process was instituted, but I have not received any information about this or any conclusions or recommendations.

Andrea has been greatly traumatised but has had good support from Jane, your bereavement midwife, Sister Williams, Dr. Jones and Susan, our health visitor. Andrea’s mother, who used to be a nurse, has made it clear that she believes Andrea’s care was negligent and that Andrea should complain. Dr. Reid is aware of this. I should be most appreciative if Andrea could be under senior review and I could have a comprehensive plan for the pregnancy and delivery so that Dr. Jones, Sister Williams and I can give her the maximum support during what is bound to be a very stressful time.

Yours sincerely,

Mary Goodfellow.

97. Viva. Asymptomatic bacteriuria and pregnancy.

Candidate’s instructions.

The examiner will ask you 14 questions – and maybe a few more as I have written this question today and may yet think of a few more.

98. Role-play. Transgender. Menorrhagia. Emily, Rob.

This question was written by Emily Wright, prompted by teaching on transgender issues by her colleague Rob Cumming.

Candidate’s instructions.

You are an ST5 doctor in the gynaecology clinic, your next patient is Mr Michael Williams; you have received the following letter from the GP.

Take a history from the patient and make a management plan.
Dear Doctor,
I would be most grateful if you could see Michael Williams, a 23-year-old transgender man. He is currently suffering with menorrhagia. He was referred to the gender identify one year ago but the waiting list for a first appointment is two years. I would be most grateful for your expert opinion - I know Michael is quite keen to discuss surgical options.