Tutorial 28 June 2021

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36	Martino Zacchè. Uro-gynae tutorial
37	EMQ. Family origin questionnaire
38	Structured conversation. Apgar score
39	SBA. Appendicitis in pregnancy
40	EMQ. Anti-D

 

36.   Uro-gynae tutorial. Martino Zacchè.

 

37.   EMQ. Family origin questionnaire

Question 1.             

What is the main purpose of the FOQ? This is an EMQ with only one correct answer.

Option list.

A	to identify illegal immigrants
B	to identify those who are not entitled to free NHS care
C	to monitor the degree to which different ethnic groups use the NHS
D	to screen for sickle cell disease
E	to screen for α-thalassaemia
F	none of the above.

Question 2.             

Whose ancestry is asked about in the FOQ? This is not a true EMQ as there may be more than one correct answer.

Option list.

A	the pregnant woman
B	the woman’s partner/husband
C	the biological father of the pregnancy
D	the postman in case he delivered more than the mail
E	the queen
F	the woman’s mother
G	the woman’s father
H	the woman’s siblings
I	none of the above

Question 3.             

Which generations should be included? This is an EMQ with only one correct answer.

Option list.

A	the current generation
B	the current generation + the previous generation
C	the current generation + 2 previous generations
D	the current generation + 3 previous generations
E	the current generation + as many previous generations as possible
F	none of the above

Question 4.             

Who should complete the FOQ? This is an EMQ with only one correct answer.

Option list.

A	the woman
B	the woman’s husband / partner
C	the biological father of the pregnancy
D	the midwife
E	the obstetrician
F	an interpreter if the woman & partner are not fluent in English
G	none of the above

Question 5.             

What other responsibilities does the person completing the FOQ have? There is no option list so as not to make it too easy.

Question 6.             

Which tick boxes are highlighted in yellow on the FAQ. This is an EMQ with one correct answer.

Option list.

A	those that must be completed
B	those that suggest a possible ↑ risk of neonatal jaundice
C	those that suggest a possible ↑ risk of HepB
D	those that suggest a possible ↑ risk of SCD. SCT or thalassaemia
E	those showing areas with a ↑ risk of having SCD. SCT or thalassaemia
F	none of the above

Question 7.             

What is the significance of the red ‘hash’ mark  # that appears alongside some of the boxes. There is only one correct answer.

Option list.

A	the box that must be completed
B	just decoration to make the form more pleasing to the eye
C	denotes area with ↑ risk of bilharzia
D	denotes area with ↑ risk of falciparum malaria
E	denotes area with ↑ risk of α-thalassaemia
F	denotes area with ↑ risk of β-thalassaemia
G	none of the above

Question 8.             

A woman books at 10 weeks in her 1^st. pregnancy. Her husband in Turkish and healthy. What screening for sickle cell and thalassaemia should be offered?

Option list.

A	screening depends on whether the area is high or low risk
B	screening depends on whether the FOQ shows high or low risk
C	the husband should first be screened
D	the woman should be screened using Hb and red cell indices
E	the woman should be screened using electrophoresis
F	none of the above

Question 9.             

A woman books at 10 weeks in her 1^st. pregnancy. Her husband is English and healthy. What screening for sickle cell and thalassaemia should be offered?

Option list.

A	screening depends on whether the area is high or low risk
B	screening depends on whether the FOQ shows high or low risk
C	the husband should first be screened
D	the woman should be screened using Hb and red cell indices
E	the woman should be screened using electrophoresis
F	none of the above

 

38.   Structured conversation. Apgar score.

The examiner will ask 8 questions.

 

39.   Appendicitis in pregnancy.              

Topic. Appendicitis in pregnancy.

Abbreviations.

AIP:                     appendicitis in pregnancy

CRP :                   C reactive protein

EFHRM:              electronic fetal heart rate monitoring

RLQP:                 right lower quadrant pain

RUQP:                right upper quadrant pain

Question  1.           

What is the approximate incidence of appendicitis in pregnancy?

Option List

A	1 in 500
B	1 in 1,000
C	1 in 2,000
D	1 in 5,000
E	1 in 10,000

Question  2.           

Is appendicitis more or less common in pregnancy?

Option List

A	just as common
B	less common
C	maybe
D	more common
E	no one knows
	no one cares

Question  3.           

How is maternal death from appendicitis classified?

Option List

A	coincidental death
B	direct death
C	incidental death
D	indirect death
E	none of the above

Question  4.           

When is appendicitis in pregnancy most common?

Option List

A	first trimester
B	second trimester
C	trimester
D	1st. and 2nd. stages of labour
E	in the hours after the 3rd. stage of labour
	during the puerperium

Question  5.           

What eponymous title is given to the surface marker for the appendix?

Option List

A	McBarney’s point
B	MacBurney’s point
C	McBurney’s point
D	MacBorney’s point
E	McBorney’s point

Question  6.           

Where is the point referred to in the above question?

Option List

A	1/3 of the way along the line joining the anterior superior iliac spine and umbilicus
B	1/2 of the way along the line joining the anterior superior iliac spine and umbilicus
C	2/3 of the way along the line joining the anterior superior iliac spine and umbilicus
D	1/3 of the way along the line joining the left and right anterior superior iliac spines
E	1/2 of the way along the line joining the left and right anterior superior iliac spines

Question  7.           

Which, if any, of the following statements are true about the person after whom the point in the above questions is named?

Statements

A	he spent 2 years as a postgraduate working in Berlin, London, Paris and Vienna
B	he was Professor of surgery at the Roosevelt hospital, New York from 1889 to 1894
C	he presented his classical paper on appendicitis to the NY Surgical Society in 1889
D	he was a transvestite
E	he died of a heart attack while on a hunting trip

Option List

1	A + B + E
2	A + C + E
3	A + B + D
4	A + B + C + D
5	A + B + C + E

Question  8.           

Pick the best option from the list below in relation to right lower quadrant pain in AIP in the pregnant and non-pregnant.

Option List

A	comparative figures for the pregnant and non-pregnant are unknown
B	RLQP is as common in the pregnant as in the non-pregnant
C	RLQP is less common in the pregnant
D	RLQP is more common in the pregnant
E	RLQP is rare in pregnancy

Question  9.           

Pick the best option from the list below in relation to right upper quadrant pain in AIP in the pregnant and non-pregnant.

Option List

A	comparative figures for the pregnant and non-pregnant are unknown
B	RUQP is ½ as common in the pregnant as in the non-pregnant
C	RUQP is as common in the pregnant as in the non-pregnant
D	RUQP is twice as common in the pregnant as in the non-pregnant
E	RUQP is four times as common in the pregnant as in the non-pregnant

Question  10.        

Pick the best option from the list below in relation to nausea in AIP in the pregnant and non-pregnant.

Option List

A	comparative figures for the pregnant and non-pregnant are unknown
B	nausea is as common in the pregnant as in the non-pregnant
C	nausea is less common in the pregnant
D	nausea is more common in the pregnant
E	nausea is rare in pregnancy

Question  11.        

Which condition did CMACE say should be excluded in women presenting acutely with gastrointestinal symptoms?

Option List

A	aortic dissection
B	appendicitis
C	Caesarean section scar pregnancy
D	ectopic pregnancy
E	pancreatitis
F	ovarian torsion

Question  12.        

Pick the best option from the list below in relation to abdominal guarding in AIP in the pregnant and non-pregnant.

Option List

A	comparative figures for the pregnant and non-pregnant are unknown
B	abdominal guarding is as common in the pregnant as in the non-pregnant
C	abdominal guarding is less common in the pregnant
D	abdominal guarding is more common in the pregnant
E	abdominal guarding is rare in pregnancy

Question  13.        

Pick the best option from the list below in relation to rebound tenderness in AIP in the pregnant and non-pregnant.

Option List

A	comparative figures for the pregnant and non-pregnant are unknown
B	rebound tenderness is as common in the pregnant as in the non-pregnant
C	rebound tenderness is less common in the pregnant
D	rebound tenderness is more common in the pregnant
E	rebound tenderness is rare in pregnancy

Question  14.        

Pick the best option from the list below in relation to fever in AIP in the pregnant and non-pregnant.

Option List

A	comparative figures for the pregnant and non-pregnant are unknown
B	fever is as common in the pregnant as in the non-pregnant
C	fever is less common in the pregnant
D	fever is more common in the pregnant
E	fever is rare in pregnancy

Question  15.        

How useful is the finding of leucocytosis in making the diagnosis of AIP?

Option List

A	sine qua non
B	very useful
C	not very useful
D	I don’t know

Question  16.        

How useful is the finding of a raised CRP level in the diagnosis of AIP?

Option List

A	sine qua non
B	very useful
C	not very useful
D	I don’t know

Question  17.        

What are the ultrasound features of appendicitis?

Option List

A	appendix with diameter > 6 mm.
B	appendix with diameter > 1 cm.
C	blind-ending tubular structure
D	non-compressible tubular structure
E	none of the above

Question  18.        

What figures do W&M give for sensitivity & specificity for US diagnosis of appendicitis?

Option List

	Sensitivity	Specificity
A	≥65%	≥80%
B	≥75%	≥85%
C	≥86%	≥97%
D	≥91%	≥98%
E	≥95%	≥95%

Question  19.        

Which, if any, of the following statements are true about CT scanning for the diagnosis of AIP?

Option List

A	CT scanning has sensitivity > 85% and specificity >95%
B	CT scanning exposes mother and fetus to radiation doses of little concern
C	CT scanning has replaced ultrasound scanning for AIP
D	CT scanning is not of proven value after inconclusive ultrasound scanning
E	CT scanning is of proven value and most useful after inconclusive ultrasound scanning

Question  20.        

Which, if any, of the following statements are true about MRI scanning for the diagnosis of AIP?

Option List

A	MRI scanning has sensitivity > 90% and specificity >97%
B	MRI scanning exposes mother and fetus to radiation doses of little concern
C	MRI scanning has replaced ultrasound scanning for AIP
D	MRI scanning is not of proven value after inconclusive ultrasound scanning
E	MRI scanning is of proven value and most useful after inconclusive ultrasound scanning

Question  21.        

Which, if any, of the following statements are true about the complications of AIP?

Option List

A	fetal loss rate in uncomplicated AIP is about 1.5%
B	fetal loss rate in AIP complicated by peritonitis is about 6%
C	fetal loss rate in AIP complicated by perforation of the appendix is up to 36%
D	pre-term delivery rates increase in AIP complicated by perforation of the appendix
E	a low level of suspicion should apply to the diagnosis of AIP in relation to surgical intervention

Question  22.        

Which, if any, of the following statements are true about surgery for AIP?

Option List

A	laparotomy should be done through a grid-iron incision with the mid-point the surface marker for the appendix in the right iliac fossa
B	laparotomy should be done through a right paramedian incision starting at the level of the umbilicus
C	about 35% of laparotomies show no evidence of appendicitis
D	the appendix should be removed even if it looks normal
E	antibiotic therapy is an alternative to surgery in early cases of acute AIP

Question  23.        

Which, if any, of the following statements are true about surgery for AIP?

Option List

A	laparoscopic appendicectomy is an acceptable alternative to laparotomy, but only in the 1st. trimester
B	laparoscopic appendicectomy is an acceptable alternative to laparotomy, but only in the 1st. & 2nd. trimesters
C	laparoscopic appendicectomy is an acceptable alternative to laparotomy, at all gestations
D	there is evidence that laparoscopic appendicectomy is associated with doubling of the rate of fetal loss
E

Question  24.        

Which, if any, of the following statements are true about C section in relation to AIP?

Option List

A	C section is rarely necessary
B	C section increases the risk of uterine infection if peritonitis is present
C	C section should be offered if elective C section is planned
D	C section should be considered if the woman is critically ill
E

Question  25.        

Which, if any, of the following statements are true about the fetal heart rate?

Option List

A	EFHRM should be done pre and post-operatively in surgery for AIP
B	EFHRM should always be done intra-operatively in surgery for AIP
C	the drugs used for GA tend to cause fetal tachycardia
D	the drugs used for GA commonly cause a sinusoidal pattern
E	C section should be done if abnormal EFHRM patterns occur
	fetal scalp pH sampling should be done if abnormal EFHRM patterns occur
	fetal blood sampling should be done if abnormal EFHRM patterns occur

 

TOG questions. These are open access, so reproduced here.

Appendicitis is a likely diagnosis in pregnancy when,

1.     ultrasound shows a non-compressible blind-ending tube in the right iliac fossa measuring 10 mm in diameter.

2.     a patient presents with right-sided abdominal pain, constipation and malaise. the RIF but often to the upper R quadrant in pregnancy.

In the diagnosis of appendicitis in pregnancy,

3.     ultrasound is the best method for imaging in a morbidly obese patient.

4.     MRI has the greatest specificity of all imaging modalities

With regard to the management of a pregnant patient with appendicitis,

5.     it should be operative if the diagnosis is certain.

6.     it should primarily aim to reduce any delay in surgical intervention.

7.     it should not involve appendicectomy if the appendix appears normal at the time of surgery.

8.     it should include delivery of the fetus regardless of gestation if the patient is critically ill.

9.     some cases may be treated with antibiotics alone.

General anaesthesia for pregnant women undergoing appendicetomy,

10.   carries ~ a 25-fold increased risk of complications than regional anaesthesia.

11.   has temporary effects on the fetus as all induction and maintenance agents cross the placenta.

12.   has a uterotonic effect.

Surgery for appendicetomy in pregnancy,

13.   increases the rate of miscarriage.

14.   has the lowest risk to the fetus when performed in the second trimester.

15.   should be delayed until antenatal corticosteroids are given (in the absence of severe maternal sepsis) if the gestation is critical.

Concerning acute appendicitis in pregnancy,

16.   it is the most common cause of acute surgical abdomen.

17.   it most commonly occurs in the first trimester.

18.   it has a fetal loss rate exceeding 50% if the appendix perforates.

With regard to imaging as an investigation for appendicitis in pregnancy,

19.   the primary goal is to rule out differential diagnoses.

20.   the secondary goal is to reduce the negative appendicectomy rate.

 

40.   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!

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 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? 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
F	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