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.

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?