40. Role-play.
Candidate’s instructions.
You are an SpR and running
the pre-pregnancy counselling clinic. You are about to see Jane Large.
The GP letter reads as
follows.
The Surgery, High Street,
Blackville.
Re: Jane Large, DOB 1
January 1991.
The Haven, 28 Backwater,
Blackville.
Dear Doctor,
Please see Jane who is
planning her first pregnancy. She is healthy apart from living up to her name
and being overweight. I have not met her before, but understand that here sister
had a Caesarean recently and this is causing her some concern.
Regards.
B. L. Ase MB.
Your task is to provide
appropriate pre-pregnancy counselling and suggest a management plan.
41. Structured
conversation. Maternity dashboard.
Candidate’s instructions.
This is a viva station
about the RCOG’s maternity dashboard. 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.
42. EMQ.
Clopidogrel.
Question
1.
What type of drug is
clopidogrel?
Option list.
|
A |
antibiotic |
|
B |
antidepressant |
|
C |
antihypertensive |
|
D |
antipsychotic |
|
E |
biologic |
|
F |
direct-acting oral
anticoagulant |
|
G |
diuretic |
|
H |
immunomodulator |
|
I |
parenteral anticoagulant |
|
J |
platelet inhibitor |
|
K |
none of the above |
Question
2.
What is the main mode of action of
clopidogrel?
Option list.
|
A |
irreversible binding to
the platelet P2Y12 ADP
receptor causing impaired platelet aggregation |
|
B |
inhibition of clotting
factor II |
|
C |
inhibition of clotting
factor VIII |
|
F |
inhibition of the
renin-angiotensin system |
|
D |
inhibition of vitamin K
metabolism |
|
G |
selective serotonin
uptake inhibition |
|
H |
peripheral vasodilation |
|
I |
none of the above |
Question
3.
Which of the
following statements is most appropriate in relation to clopidogrel in planned
surgery for patients taking clopidogrel?
Option list.
|
A |
acupuncture should be
substituted for the surgery |
|
B |
diazepam should be added
post-operatively |
|
C |
the surgery can go ahead
after anaesthetic review |
|
D |
the surgery can go
ahead, but careful blood pressure monitoring is essential |
|
E |
the drug should be
discontinued at least 10 days before surgery |
|
F |
none of the above. |
Question
4.
Which of the following
statements is most appropriate in relation to clopidogrel in emergency surgery
for patients taking clopidogrel?
Option list. Use the list for the
previous question.
Question
5.
What is the advice about the use of
clopidogrel in pregnancy?
Option list.
|
A |
it is contraindicated
because of an increased risk of APH |
|
B |
it is contraindicated
because of an increased risk of bleeding after miscarriage |
|
C |
it is contraindicated
because of an increased risk of fetal abnormality |
|
D |
it is contraindicated
because of an increased risk of PPH |
|
E |
it is contraindicated
because there is insufficient data about its safety |
|
F |
none of the above |
Question
6.
What is the advice about the use of
clopidogrel during breastfeeding?
Option list.
|
A |
it is contraindicated
because of an increased risk of postnatal depression |
|
B |
it is contraindicated
because of an increased risk of PPH |
|
C |
it is contraindicated
because of an increased risk of pulmonary embolism |
|
D |
it is contraindicated
because of an increased risk of posterior reversible encephalopathy syndrome |
|
E |
it is contraindicated
because there is insufficient data about its safety |
|
F |
none of the above |
You might think
this so ‘small print’ that you should ignore it. There was a TOG article in
2018, so it is a hot topic and you need a grasp of the basics.
Abbreviations.
ADH: antidiuretic hormone.
Scenario 1.
What is the origin of the word ‘diabetes’?
Option
list.
|
A. |
the Greek word
for ‘bucket’ |
|
B. |
the Greek word
for ‘halitosis’ |
|
C. |
the Greek word
for ‘siphon’ |
|
D. |
the Greek word
for ‘stream’ |
|
E. |
the Greek word
for ‘waterfall’ |
Scenario 2.
What
is the origin of the word ‘mellitus’?
Option
list.
|
A. |
the Latin word
for ‘darling’ |
|
B. |
the Latin word
for ‘honeyed’ |
|
C. |
the Latin word
for ‘honey-pie’ |
|
D. |
the Latin word
for ‘sugar’ |
|
E. |
the Latin word
for ‘sweet’ |
Scenario 3.
What
is the origin of the word ‘insipidus’?
Option
list.
|
A. |
the Latin word for ‘dull’ |
|
B. |
the Latin word for ‘pale grey’ |
|
C. |
the Latin word for ‘savoury’ |
|
D. |
the Latin word for ‘spicy’ |
|
E. |
the Latin word ‘to have taste’ |
Scenario 4.
What is the origin of the word ‘insulin’?
Option
list.
|
A. |
the Latin noun
‘insula’, ‘island’ to reflect its production in the islets of Langerhans |
|
B. |
the Latin verb
‘insultare’ ‘to insult’ as this is an affront to your intelligence |
|
C. |
the Latin verb
‘insultare’, ‘to assault’; reflecting its ability to deal with DM |
|
D. |
the Latin verb
‘insulare’, ‘to insulate’; reflecting its ability to protect from DM |
|
E. |
none of the
above |
What is the definition of DI?
Option list.
|
A. |
diabetes mellitus with low or normal blood glucose
levels |
|
B. |
diabetes mellitus with low serum osmolality |
|
C. |
diabetes mellitus with polyuria despite low or
normal blood glucose levels |
|
D. |
failure of the renal glomeruli to conserve water |
|
E. |
failure of the renal tubules to conserve water |
|
F. |
polyuria with urine output > 3 litres per 24
hours |
|
G. |
polyuria with urine output > 5 litres per 24
hours |
|
H. |
polyuria and polydipsia due to low or absent ADH
production |
|
J. |
polyuria and polydipsia due to excess ADH
production |
|
K. |
polyuria and polydipsia due to low or absent
vasopressinase production |
|
L. |
polyuria and polydipsia due to excess ADH
vasopressinase production |
|
M. |
none of the above. |
Scenario 6.
What
is the definition of polyuria?
Option
list.
|
A. |
urine volume ≥ 2 l. per 24 hours |
|
B. |
urine volume ≥ 3 l. per 24 hours |
|
C. |
urine volume ≥ 4 l. per 24 hours |
|
D. |
urine volume ≥ 5 l. per 24 hours |
|
E. |
urine volume ≥ 10 l. per 24 hours |
|
F. |
urine volume > fluid intake |
|
G. |
urine volume
> fluid intake minus estimated ‘imperceptible’ fluid loss |
|
H. |
none of the
above |
Scenario 7.
What
is the approximate incidence of DI in pregnancy?
Option
list.
|
A. |
2-4 per
million |
|
B. |
2-4 per
100,000 |
|
C. |
2-4 per 10,000 |
|
D. |
2-4 per 1,000 |
|
E. |
none of the
above |
Scenario 8.
Which,
if any, of the following are included in the classification of DI?
Option
list.
|
A. |
central |
|
B. |
dipsogenic |
|
C. |
dipsomaniacal |
|
D. |
gestational |
|
E. |
neurotic |
|
F. |
nephrogenic |
|
G. |
neurogenic |
|
H. |
peripheral |
|
I. |
primary |
|
J |
psychogenic |
|
K. |
renal |
Scenario 9.
Which, if any, of the following are the
most common type of DI in the non-pregnant? There may be more than one correct
answer as some of the terms are used synonymously.
Option
list.
Use the option
list from question 8.
Scenario 10.
Which, if any, of the following are the
most common type of DI in pregnancy? There may be more than one correct answer
as some of the terms are used synonymously.
Option
list.
Use the option
list from question 8.
Scenario 11.
Which, if any, of the following apply to
ADH?
Option
list.
|
A. |
it is an
octapeptide |
|
B. |
it is a nonapeptide |
|
C. |
it is a
decapeptide |
|
D. |
it is a
glycoprotein |
|
E. |
none of the
above |
Scenario 12.
Which,
if any, of the following are true in relation to the mechanisms controlling
release of ADH?
Option
list.
|
A. |
the main
factor controlling ADH release is plasma albumin |
|
B. |
the main
factor controlling ADH release is plasma albumin |
|
C. |
the main
factor controlling ADH release is plasma osmolality |
|
D. |
the main
factor controlling ADH release is plasma sodium |
|
E. |
the main
factor controlling ADH release is plasma viscosity |
|
F. |
the main
factor controlling ADH release is plasma volume |
Scenario 13.
Which,
if any, of the following is true about the effect of ADH?
Option
list.
|
A. |
it ↑ the creation of aquaporins |
|
B. |
it ↑ the creation of aquapourins |
|
C. |
it ↑ the creation of aquasporrins |
|
D. |
it ↓ the creation of aquaporins |
|
E. |
it ↓ the creation of aquapourins |
|
F. |
it ↓ the creation of aquasporrins |
|
G. |
none of the above |
Scenario 14.
Which,
if any, of the following statements are true about the V1 receptors?
Option list.
|
A. |
they are
stimulated by ADH |
|
B. |
high ADH
levels cause vasoconstriction |
|
C. |
high ADH
levels cause vasodilatation |
|
D. |
high ADH
levels ↑ reabsorption
of water |
|
E. |
high ADH
levels ↓ reabsorption
of water |
Scenario 15.
Which,
if any, of the following statements are true about the V2 receptors?
Option list.
|
A. |
they are
stimulated by ADH |
|
B. |
high ADH
levels cause vasoconstriction |
|
C. |
high ADH
levels cause vasodilatation |
|
D. |
high ADH
levels ↑ reabsorption
of water |
|
E. |
high ADH
levels ↓ reabsorption
of water |
Scenario 16.
Which,
if any of the following statements is true about ADH?
Option
list.
|
A. |
it is produced
by the hypothalamus |
|
B. |
it is produced
by the anterior pituitary |
|
C. |
it is produced
by the posterior pituitary |
|
D. |
shares all but
two of its peptides with oxytocin |
|
E. |
acts on the V1
renal receptors to ↑ reabsorption
of water |
|
F. |
acts on the V1
renal receptors to ↑
vasoconstriction |
|
G. |
acts on the V2
renal receptors to ↑ reabsorption
of water |
|
H. |
acts on the V2
renal receptors to ↑ reabsorption
of water |
|
I. |
ADH secretion
increases x 4 by the 3rd. trimester |
|
J. |
has got me
bored out of my head |
Scenario 17.
Which,
if any, of the following statements best fits the changes in systemic vascular
resistance?
Option
list.
|
A. |
it falls from
the 1st. to the 3rd. trimester |
|
B. |
it falls from
the 1st. to the mid-2nd. trimester |
|
C. |
it falls from
the 2nd. to the 3rd. trimester |
|
D. |
it rises from
the 1st. to the 3rd. trimester |
|
E. |
it rises from
the 1st. to the mid-2nd. trimester |
|
F. |
it rises from
the 2nd. to the 3rd. trimester |
|
G. |
none of the
above |
Scenario 18.
Which,
if any, of the following are correct in relation to vasopressinase?
Option
list.
|
A. |
it is mainly
produced in the fetal liver |
|
B. |
it is mainly
produced by trophoblasts |
|
C. |
vasopressinase
activity is directly proportionate to the liquor volume |
|
D. |
vasopressinase
activity is directly proportionate to the weight of the fetus |
|
E. |
vasopressinase
activity is directly proportionate to the weight of the placenta |
|
F. |
vasopressinase
activity is similar with ADH and DDAVP |
Scenario 19.
Which,
if any, of the following investigations may be appropriate in DI in pregnancy?
Option
list.
|
A. |
urea &
electrolytes |
|
B. |
blood glucose |
|
C. |
urine glucose |
|
D. |
blood calcium |
|
E. |
plasma
osmolality |
|
F. |
urine osmolality |
|
G. |
urine specific
gravity |
|
H. |
MRI scan |
Which, if any, of the following statements
are true about DDAVP?
Option list.
|
A. |
It is also known vasopressin |
|
B. |
it is also known as dismopressin |
|
C |
is resistant to vasopressinase |
|
D. |
it is believed to be safe in pregnancy |
|
E. |
it may cause delayed onset of labour |
|
F. |
it may cause dysfunctional labour |
|
G. |
it may cause hypernatraemia |
|
H. |
it may cause precipitate labour |
|
I. |
it may increase the risk of retention of the
placenta and PPH |
|
J. |
it may interfere with the initiation of lactation |
|
K. |
it is usually administered nasally |
|
L. |
is the treatment of choice for central DI |
|
M. |
is the treatment of choice for gestational DI |
|
N. |
is the treatment of choice for nephrogenic DI |
|
O. |
is the treatment of choice for psychogenic DI |
CPD
question from TOG 2018. Vol 20; 1. These are open access, so reproduced here.
Diabetes insipidus (DI) in pregnancy,
1. is the
failure of water conservation by the renal tubules. True / False
2. occurs
in approximately 2–4 per 100 000 pregnancies. True / False
3. is
associated with a mortality rate of approximately 50%. True / False
4. usually
arises in the first trimester. True / False
5. presents
with oliguria. True / False
Antidiuretic hormone (ADH),
6. acts at
the kidney by stimulating V2 receptors. True / False
7. has a
similar structure to oxytocin. True / False
Vasopressinase,
8. is
released from the fetal renal vasculature. True / False
9. undergoes
hepatic metabolism. True / False
10. secretion
is increased in multiple pregnancies. True / False
Regarding the pathophysiology of DI,
11. the
neurogenic (central) type is caused by either inadequate production or release
of vADH from the posterior pituitary. True / False
12. in the
gestational type ADH synthesis is unaffected. True / False
13. primary
polydipsia occurs as a result of excess fluid intake with normal pituitary and
renal function. True / False
Desmopressin (1-deamino-8-D-arginine vasopressin,
DDAVP),
14. is an ADH
analogue. True / False
15. is a
second-line treatment in pregnancy for the non-renal type of DI. True / False
16. can be
administered rectally. True / False
17. is
administered intravenously. True / False
Pregnant women with DI,
18. can be
managed solely with obstetric input. True / False
19. have a
good prognosis if its uncomplicated. True / False
20. will
require senior clinician (obstetrics and anaesthetics) review in < 5% of
cases. True / False
44. Montgomery
Ruling. EMQ. Question.
Abbreviations.
BMA: British Medical Association.
GMC: General Medical Council.
MR: Montgomery Ruling.
Question 1.
Which, if any, of the following statements is most accurate?
Lead-in
|
A |
The MR largely replaces the Bolam ruling |
|
B |
The MR largely replaces
the Chester ruling |
|
C |
The MR largely replaces
the Sidaway ruling |
|
D |
The MR is being
contested in the European Court by the GMC as it infringes doctors’ rights |
|
E |
The MR is being
contested in the European Court by the BMA as it infringes doctors’ rights |
Question 2.
Which, if any, of the following statements are true? This is not a true
EMQ as > 1 of the answers may be correct.
Lead-in
|
A |
the level of risk, however small, must be disclosed if a patient
requests it |
|
B |
the level of risk of
damage from a procedure need not be disclosed if < 1% |
|
C |
the level of risk of
damage from a procedure need not be disclosed if < 10% |
|
D |
a material risk is one
that would be reflected in damages > £100,000 if negligence were proved in
court |
|
E |
a material risk is one
that would be reflected in damages > £1,000,000 if negligence were proved
in court |
|
F |
a material risk is one
that involves anatomical damage, not emotional or psychological |
|
G |
a material risk is one
that a reasonable person in the patient’s situation would be likely to
regards as significant |
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