|
52 |
EMQ. Anti-D. |
|
53 |
EMQ. Tranexamic acid. |
|
54 |
Structured conversation. Apgar
score. |
|
55 |
SBA. McCune-Albright syndrome |
|
56 |
EMQ. Uterine inversion. |
52. EMQ.
Anti-D.
Abbreviations.
cffDNA: cell-free, fetal DNA.
DAT: direct anti-globulin test.
FDIU: fetal death in utero.
HDFN: haemolytic disease of the fetus and
newborn.
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.
TOP: termination of pregnancy.
Scenarios.
There
is no option list for many questions to force good technique and save me lots
of typing!
Question 1.
What proportion of the Caucasian population in the UK has Rh-ve blood
group?
Question 2.
What proportion of the Rh+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 were not be given anti-D as a matter of policy?
Question 9.
List the possible reasons that a Rh-ve mother with a Rh+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 RhDu 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? The
GTG has been archived, but I left this question to illustrate the point about ‘offered’
and ‘considered’.
Question 21.
A Rh-ve woman miscarries a Rh+ve fetus at 18 week’s gestation.
What should be done about Rhesus prophylaxis?
Question 22.
A Rh-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 dose 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 Rh-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 significant 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,
if any, of the following 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.
A woman has a potentially sensitising event at 16 weeks.
Which, if any, of the following 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 34.
A woman has a potentially sensitising event at 22 weeks.
Which, if any, of the following 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 35.
A woman has a potentially sensitising event at 32 weeks.
Which, if any, of the following 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 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 Rh+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.
|
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 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.
A Rh-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.
|
A |
antibody screen |
|
B |
cffDNA |
|
C |
DAT |
|
D |
Kleihauer test |
|
E |
maternal blood group |
Question 40.
A Rh-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 Rh-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 Rh-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 Rh-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 |
|
None
of the above. |
Question 45.
Which,
if any, of the following statements is true about current use of cffDNA for
determination of the fetal Rhesus blood group in the NHS?
Option List.
|
A |
it
is recommended for all Rh-ve women |
|
B |
it
is recommended for consideration prior to RAADP use |
|
C |
it
is recommended for all Rh-ve women prior to RAADP use |
|
D |
it
is recommended for all Rh+ve women prior to RAADP use |
|
E |
it
is not yet approved for use |
|
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.
55. SBA. McCune-Albright
syndrome.
Abbreviations.
MCA: McCune Albright syndrome.
Scenario 1.
Which, if any, of the following are components
of the classical triad of MCA?
Option
List
|
A |
albinism |
|
B |
“cafè Cubano” spots feature |
|
C |
“Coast of California” pigmented areas |
|
D |
lentigo |
|
E |
osteomalacia |
|
F |
polyostotic fibrous dysplasia |
|
G |
precocious puberty |
|
H |
premature menopause |
|
I |
primary amenorrhoea |
Scenario 2.
Which, if any, of the following are true in
relation to MCA?
Option
List
|
A |
it is an example of central primary amenorrhoea |
|
B |
it is an example of central secondary amenorrhoea |
|
C |
it is an example of central precocious puberty |
|
D |
it is an example of peripheral primary amenorrhoea |
|
E |
it is an example of peripheral secondary amenorrhoea |
|
F |
it is an example of peripheral precocious puberty |
|
G |
none of the above |
Scenario 3.
Which, if any, of the following are true in
relation to MCA?
Option
List
|
A |
hyperthyroidism is common |
|
B |
hypothyroidism is common |
|
C |
thyroid function is similar to those without MCA |
Scenario 4.
Which, if any, of the following are true in
relation to MCA?
Option
List
|
A |
excess growth hormone production is common |
|
B |
inadequate growth hormone production is common |
|
C |
growth hormone production is similar to those without MCA |
Scenario 5.
Which, if any, of the following is true in
relation to MCA?
Option
List
|
A |
inheritance is autosomal dominant |
|
B |
inheritance is autosomal recessive |
|
C |
inheritance is X-linked dominant |
|
D |
inheritance is X-linked recessive |
|
E |
inheritance is multifactorial |
|
F |
it is not a hereditary disorder |
|
G |
the aetiology is not genetic |
|
H |
none of the above |
Scenario 6.
Which, if any, of the following are true in
relation to MCA?
Option
List
|
A |
renal artery stenosis is more common |
|
B |
renal cortex wasting is more common |
|
C |
renal phosphate wasting is more common |
|
D |
renal waisting is more common |
|
E |
none of the above. |
Scenario 7.
Approximately what % of children born to
women with MCAS will have MCAS?
Option
List
|
A |
0 |
|
B |
1 in 105 - 106 |
|
C |
1 in 104 |
|
D |
1 in 100 |
|
E |
1 in 50 |
|
F |
1 in 10 |
|
G |
1 in 2 |
|
H |
All |
56.
EMQ. Uterine inversion. .
Abbreviations.
MROP: manual removal of placenta.
UI: uterine inversion.
Question
1.
How is uterine inversion categorised and what how are the
categories defined? This is not an EMQ and there is no option list.
Question
2.
What
is the approximate incidence of UI?
Option
list.
|
A |
1 in 1,000 |
|
B |
1 in 2,000 |
|
C |
1 in 4,000 |
|
D |
1 in 6,000 |
|
E |
1 in 10,000 |
|
F |
1 in 20,000 |
|
G |
1 in 100,00 |
Question
3.
Is
the incidence of UI higher in less-well developed countries?
Option
list.
|
A |
answer unknown |
|
B |
no |
|
C |
yes |
Question
4.
What
is the approximate incidence of UI during Caesarean section?
Option
list.
|
A |
1 in 1,000 |
|
B |
1 in 2,000 |
|
C |
1 in 4,000 |
|
D |
1 in 6,000 |
|
E |
1 in 10,000 |
|
F |
1 in 20,000 |
|
G |
1 in 100,00 |
Question
5.
Which,
if any, of the following are described as risk factors for UI?
Option
list.
|
A |
abruptio placenta |
|
B |
Caesarean section |
|
C |
Credé’s manoeuvre |
|
D |
fundal placenta |
|
E |
hydramnios |
|
F |
lax uterus |
|
G |
Marfan syndrome |
|
H |
mismanagement of the 2nd. stage of labour |
|
I |
mismanagement of the 3rd. stage of labour |
|
J |
oxytocic use |
|
K |
postpartum haemorrhage |
|
L |
short cord |
Question
6.
What
are the presenting features of UI? There is no option list.
Question
7.
What is
the immediate management of UI? There is no option list.
Question
8.
What procedure should be considered if the inversion is not
corrected during initial management? There is no option list.
Question
9.
What is
Huntington’s procedure?.
Question
10.
What
is Haultain’s procedure ?
Question
11.
What other
procedures have been described? There is no option list.
Question
12.
What should be done to ensure the inversion does not recur after
successful replacement? There is no option list.
Question
13.
What is
the risk of recurrence in the next pregnancy? There is no option list.
Acute inversion of the uterus
With regard to acute uterine inversion,
1 it is spontaneous in up to 50% of cases. True / False
2 its incidence is similar in most parts of the
world. True / False
The
associated risk factors for acute inversion of the uterus include:
3 injudicious traction on the umbilical cord.
True / False
4 manual removal of the placenta. True / False
5 uterine atony. True / False
6 fundal implantation of a morbidly adherent
placenta. True / False
7 placenta praevia. True / False
Recognised
features of acute inversion of the uterus include:
8 haemorrhage. True / False
9 neurogenic shock. True / False
10 severe abdominal pain. True / False
11 postpartum collapse. True / False
12 lump per vaginam. True / False
Regarding
management of acute uterine inversion,
13 the best treatment is immediate repositioning
of the uterus. True / False
14 the use of tocolysis to promote uterine relaxation
will aid uterine reposition. True / False
15 magnesium sulphate is not used for tocolysis.
True / False
16 in the presence of shock, terbutaline is
acceptable as a safe agent for uterine
relaxation.
True / False
17 when halothane is used to encourage uterine relaxation
severe hypotension is a recognised complication. True / False
With
regard to future pregnancy,
18 the condition carries a good prognosis if managed
correctly. True / False
Regarding
treatment of acute inversion,
19 in fewer than 3% of cases, women will need
to undergo laparotomy. True / False
20 immediate reduction is successful in
approximately 50–80% of cases. True / False
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