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51	Uro-gynae tutorial. Martino
52	EMQ. Anti-D.
53	EMQ. Tranexamic acid.
54	Structured conversation. Apgar score.

 

51.   Uro-gynae tutorial. Martino.

 

52.   EMQ. Anti-D.

Abbreviations.

BSE:            bovine spongiform encephalopathy.

CJD:            Creutzfeldt - Jakob disease.

cffDNA:      cell-free, fetal DNA.

DAT:           direct anti-globulin test.

FDIU:          fetal death in utero.

Ig:               immunoglobulin.

ICS:             intra-operative cell salvage.

i.m:             intra-muscular

NIFBG:       non-invasive fetal blood grouping

NIPT:          non-invasive prenatal testing

RAADP:      routine antenatal anti-D prophylaxis.

RBC:           red blood cells.

RhDAI:       Rhesus D alloimmunisation.

s.c:              sub-cutaneous

             

Question 1.             

What proportion of the Caucasian population in the UK has Rh –ve blood group?         

Question 2.             

What proportion of the Rhesus +ve Caucasian population is homozygous for RhD?    

Question 3.             

What is the chance of a Rh –ve woman with a Rh +ve partner having a Rh –ve child?

Question 4.             

When was routine postnatal anti-D prophylaxis introduced in the UK?

Question 5.             

Where does anti-D for prophylactic use come from?

Question 6.             

How many deaths per 100,000 births were due to RhAI up to 1969?

Question 7.             

How many deaths per 100,000 births were due to RhAI in 1990?

Question 8.             

Anti-D was in short supply in 1969. Which non-sensitised Rh –ve primigravidae with Rh +ve babies would not be given anti-D as a matter of policy?     

Question 9.             

List the possible reasons that a Rhesus –ve mother with a Rhesus +ve baby who does not receive anti-D might not become sensitised?                                                                                                                         

Question 10.         

What is the UK policy for the administration of anti-D after a term pregnancy?

Question 11.         

What is the alternative name of the Kleihauer test?

Question 12.         

What does the Kleihauer test do?

Question 13.         

How does the Kleihauer test work and what buzz words should you have in your head?

Question 14.         

When should a Kleihauer test be done after vaginal delivery?

Question 15.         

What blood specimen should be sent to the laboratory for a Kleihauer test?

Question 16.         

What steps should be taken to prevent sensitisation in the woman whose blood group is RhD_u and whose baby is Rh +ve?

Question 17.         

The Kleihauer test is of value in helping to decide if antenatal vaginal bleeding or abdominal pain are due to placental abruption, with a +ve test confirming FMH and making abruption highly probable.  True/False?

Question 18.         

When should anti-D be offered?         

Question 19.         

When should a Kleihauer test be considered?                                                                               

Question 20.         

How often does the word “considered” feature in the GTG?

Question 21.         

A Rhesus –ve woman miscarries a Rh +ve fetus at 18 week’s gestation. What should be done about Rhesus prophylaxis?

Question 22.         

A Rhesus –ve woman miscarries a Rh +ve fetus at 20 week’s gestation. What should be done about Rhesus prophylaxis?

Question 23.         

Which potentially sensitising events are mentioned in the GTG?

Question 24.         

What factors are listed in the GTG as particularly likely to be linked to FMH > 4 ml?

Question 25.         

A woman has recurrent bleeding from 20 weeks. What should be done about Rh prophylaxis?

Question 26.         

What are the key messages about giving RAADP?

Question 27.         

Which of the following statements, if any, is true of Rhesus negative volunteers given what should be a sensitising doses of Rh D?

A	all will produce anti-D
B	95% will produce anti-D
C	90 % will produce anti-D
D	80 % will produce anti-D
E	none of the above

Question 28.         

When a Rhesus –ve woman develops antibodies after a pregnancy, in what percentage of cases is the sensitising event identified?

A	10%
B	20%
C	30%
D	40%
E	>50%

Question 29.         

Which, if any, of the following statements is associated with an increased risk of Rhesus alloimmunisation?

A	anti-D occurring after a 1st. pregnancy
B	anti-D occurring after a 2nd. pregnancy
C	anti-D occurring after a 3rd. pregnancy
D	anti-D occurring after a 4th. pregnancy
E	anti-D occurring after multiple pregnancy

Question 30.         

A woman has FMH > 4ml. An appropriate additional dose of anti-D Ig is administered i.m. after taking advice from the consultant haematologist. When should a follow-up test be done to ensure that the fetal cells have been eliminated from the maternal circulation?

Question 31.         

A woman has FMH > 4ml. An appropriate dose of anti-D Ig is administered i.v. after taking advice from the consultant haematologist. When should a follow-up test be done to ensure that the fetal cells have been eliminated from the maternal circulation?

Question 32.         

A woman has a potentially sensitising event at < 12 weeks. Which investigations should be done?

Option list.

A	cffDNA
B	DAT
C	Kleihauer or equivalent test for feto-maternal haemorrhage
D	maternal blood group & antibody screen for anti-D
E	none of the above

Question 33.        Use the list from question 32

A woman has a potentially sensitising event at 16 weeks. Which investigations should be done?

Option list.

Question 34.        Use the list from question 32

A woman has a potentially sensitising event at 22 weeks. Which investigations should be done?

Option list. Use the list from question 32

Question 35.         

A woman has a potentially sensitising event at 32 weeks.

Which, if any, of the following investigations should be done?

Option list. Use the list from question 32

Question 36.         

A woman has a potentially sensitising event. The laboratory is uncertain about her Rhesus group and declares the test to be indeterminate. How should the situation be dealt with?

Option list.

A	treat her as Rhesus -ve until a definitive result is available
B	treat her as Rhesus +ve until a definitive result is available
C	treat her as Rh Du until a definitive result is available
D	refer her to a fetal medicine expert
E	none of the above

Question 37.         

A woman has a complete miscarriage at 10 weeks confirmed by ultrasound scan. Which, if any, of the following investigations would be appropriate?

Option list. Use the list from question 32

Question 38.         

A primigravida has a threatened miscarriage at 10 weeks. An ultrasound scan shows a viable intrauterine pregnancy. Which, if any, of the following investigations would be appropriate?

Option list.

A	antibody screen
B	cffDNA
C	DAT
D	Kleihauer test
E	maternal blood group

Question 39.        Use the list from question 38.

A Rhesus –ve woman has a painless APH at 30 weeks. An ultrasound scan shows a viable intrauterine pregnancy. Which, if any, of the following investigations would be appropriate?

Option list.

Question 40.         

A Rhesus –ve woman has a molar pregnancy identified and evacuated using suction at 10 weeks gestation. Which of the following statements, if any, is true?

Option list.

A	complete molar pregnancies have no fetal tissue so cannot be involved in Rh sensitisation
B	incomplete molar pregnancies have fetal tissue and can be involved in Rh sensitisation
C	molar pregnancies have significant potential for triggering Rh sensitisation
D	molar pregnancies generate potentials < 24 volts so cannot be involved in Rh sensitisation
E	none of the above

Question 41.         

A Rhesus –ve woman has a FDIU at 37 weeks. She declines intervention. Which, if any, of the following investigations should be offered?

A	DAT
B	Kleihauer or equivalent test for feto-maternal haemorrhage
C	maternal blood group & antibody screen for anti-D
D	placental biopsy
E	none of the above

Question 42.         

A Rhesus –ve woman has a FDIU at 37 weeks. She declines intervention and goes into labour at 40 weeks. She has a normal delivery but required manual removal of the placenta.

Which of the following statements, if any, are true about Rhesus prophylaxis?

Option list.

A	FMH estimation is important in relation to the FDIU
B	FMH estimation is important in relation to the mode of delivery & complications
C	FMH is minimal after FDIU and Rh D prophylaxis is irrelevant
D	FMH may have been the cause of the FDIU
E	None of the above and I am really fed up with this topic.

Question 43.         

A woman develops evidence of sudden-onset “fetal distress” in labour, C section is performed and an anaemic baby is delivered. FMH is suspected to be the cause of the “fetal distress” and the anaemia. When should samples of maternal blood be collected for testing for FMH?

Option List.

A	When the decision for C section was taken
B	At the time of delivery
C	30 – 120 minutes after the likely time of the FMH
D	4 hours after the likely time of the FMH
E	all of the above
F	none of the above

Question 44.         

A Rhesus –ve mother has C. section during which ICS is used. The baby’s blood group is Rh +ve. What is the minimum recommended dose of anti-D after return of the salvaged fetal red cells?

Option List.

A	250 IU
B	500 IU
C	1,000 IU
D	1,500 IU
E	2,000 IU
F	None of the above.

 

53.   EMQ. Tranexamic acid.

This topic featured in the exam in 2019.

Abbreviations.

GOH:          Goh E et al: “Perioperative management of women on oral anticoagulants and antiplatelet agents undergoing gynaecological procedures”.

TOG. 2020. Vol 22, Issue 2; Pages 131-6.

TA:              tranexamic acid.

Scenario 1.              

Which, if any, of the following describe the main mode of action of tranexamic acid? This is not a true EMQ as there may be more than one correct answer.

Option list.

A	inhibition of conversion of plasminogen to plasmin
B	inhibition of fibrinolysis
C	inhibition of factor Xa
D	inhibition of heparin activity
E	inhibition of plasmin activity
F	promotion of conversion of fibrinogen to fibrin
G	promotion of conversion of prothrombin to thrombin
H	promotion of platelet activation
I	promotion of platelet production

Scenario 2.              

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

Option list.

A	GOH say that TA should be considered when an apixaban antagonist is required
B	GOH say that TA should be considered when a clopidogrel antagonist is required
C	GOH say that TA should be considered when a factor Xa agonist is required
E	GOH say that TA should be considered when a factor Xa antagonist is required
F	GOH say that TA should be considered when a heparin  antagonist is required
G	GOH say that TA should be considered when Protein C is deficient
H	GOH say that TA should be considered when Protein S is deficient
I	none of the above

Scenario 3.              

Which, if any, of the following statements are true in relation to TA? This is not a true EMQ as there may be more than one correct answer.

Option list.

A	TA is teratogenic in rats and should be avoided in the first trimester
B	TA has not been shown to be teratogenic and is safe to use in pregnancy
C	TA is excreted is contraindicated in breastfeeding as the levels equate to maternal levels
D	TA levels in breast milk are one hundredth of maternal levels
E	none of the above.

Scenario 4.              

Which, if any, of the following statements are listed by eMC as contraindications?

Option list.

A	asthma
B	barbiturate use
C	consumption coagulopathy
D	convulsions
E	severe renal impairment

 

54.   Structured conversation. Apgar score.

The examiner will ask 8 questions.