Tutorial 7th. February 2022

Contact us.

Website.

7 February 2022.

 

18	Role-play. Pre-pregnancy counselling. Anaemia. ↑ MCV
19	Role-play. Pre-pregnancy counselling. Balanced t(14;21) carrier
20	EMQ. Apgar score
21	EMQ. Tranexamic acid

 

18.         Role-play. Pre-pregnancy counselling. Anaemia. ↑ MCV.

Candidate’s instructions.

This is a role-play station. You are a SpR 5 and running the pre-pregnancy counselling clinic. You are about to see Philomena Blott.

GP referral letter.

Health Horizons,

34 Main Road,

Betterworld. BW9HJ.

Re Philomena Blott,

DOB: 11 January 1995.

Dear Doctor,

Please see Philomena who is planning her first pregnancy. Her health is good and she has no significant medical or surgical history. She had her first cervical smear recently and that was normal. She had the HPV vaccine at school, so I imagine that this was to be expected. She is a bit overweight and I have advised her about healthy eating in pregnancy.

I arranged some basic blood tests. She is immune to rubella. Her FBC shows her to be a bit anaemic: the Hb was 105 gm/l with an MCV of 105fL. I suspect that she is iron and folate deficient. I have given her a prescription for oral iron and 5mg. folic acid daily. She takes the combined oral contraceptive and I have suggested that she have a repeat FBC before she stops it I have said that if her Hb is normal it would then make sense to switch to a combined iron and vitamin preparation designed for pregnancy that she can get from her chemist.

She works in the Grand Hotel in the village. If you don’t know it, I should mention that it has a very good restaurant, which I can recommend; my favourite is their beef Stroganoff. Delicious! And their house red is excellent and good  value for money.

Her husband is a sales representative for a machine tool company and travels a lot, but he is home most evenings. They seem to get on well and there is no sniff of domestic abuse.

John Williams.

 

19.         Role-play. Pre-pregnancy counselling. Balanced t(14;21) carrier.

Candidate’s instructions.

You are about to see Jenny Williams. She has come to the clinic for the results of a blood test to see if she is a carrier of a balanced translocation causing an increased risk of Down’s syndrome. You have read the notes and are aware that Jenny’s sister had been aware during the pregnancy that the baby was at increased risk for Down’s syndrome after a +ve screening test but had declined invasive testing because she would not have had TOP on religious grounds. Jenny was reluctant to ask her sister if the possibility of the baby’s condition being familial, so she was tested to see if she had a balanced translocation. The result shows t(14:21). Jenny asked to see the doctor she saw at the previous visit, but she is off sick and you have been asked to see her. Your task is to deal with the situation as you would in clinic.

 

20.         Apgar score.

Candidate's Instructions.

This is a viva station. The examiner will ask you 8 questions. You are not allowed to return to earlier questions. You will not be awarded any marks if you do, even for correct answers.

21.         Tranexamic acid.

This topic featured in the exam in 2019 and 2021. probably prompted by WHOT.

Abbreviations.

EBL:               estimated blood loss.

PPH:              postpartum haemorrhage.

TA:                tranexamic acid.

WHOT:         WHO’s “Updated WHO Recommendation on TA for the Treatment of PPH”. 2017.

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?

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
D	GOH say that TA should be considered when a factor Xa antagonist is required
E	GOH say that TA should be considered when a heparin  antagonist is required
F	GOH say that TA should be considered when Protein C is deficient
G	GOH say that TA should be considered when Protein S is deficient
H	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

Scenario 5.             Which, if any, of the following is included in the definition of PPH in WHOT?

Option list.

A	EBL  ≥ 500 mL after vaginal birth or C section
B	EBL  ≥ 1,00 mL after vaginal birth or C section
C	EBL  ≥ 500 mL after vaginal birth or ≥ 1,00 mL C section
D	EBL  ≥ 1,000 mL after vaginal birth or ≥ 500 mL C section
E	none of the above

Scenario 6.             What other category of patient is included in the WHOT definition of PPP?

Option list. There is none, to make you think.

Scenario 7.             Which of the following are included in the WHOT recommendations?

Option list.

A	TA to be given to all women with a history of PPH
B	TA to be given to all women in established labour
C	TA to be given to all having C section
D	TA to be given to all women having episiotomy
E	TA to be given to all women having instrumental delivery
F	none of the above

Scenario 8.             Which, if any, of the following are included in WHOT?

Option list.

A	TA should be given within 3 hours of the birth
B	TA should be given within 6 hours of the birth
C	TA should be given IV as a bolus of 10g
D	TA should be given IV at a dose of 1g in 10mL over 5 minutes
E	TA should be given IV at a dose of 1g in 10mL over 10 minutes
F	TA should be given IV at a dose of 5g in 20mL over 5 minutes
G	TA should be given IV at a dose of 5g in 20mL over 10 minutes

Scenario 9.             Which, if any, of the following statements is included WHOT?

Option list.

A	the benefit from TA declines by about 10% for every 5 minutes of delay in starting Rx
B	the benefit from TA declines by about 10% for every 10 minutes of delay in starting Rx
C	the benefit from TA declines by about 10% for every 15 minutes of delay in starting Rx
D	the benefit from TA declines by about 10% for every 20 minutes of delay in starting Rx
E	the benefit from TA declines by about 10% for every 25 minutes of delay in starting Rx
F	the benefit from TA declines by about 10% for every 30 minutes of delay in starting Rx
G	none of the above

Scenario 10.          Which, if any, of the following statements are included in WHOT?

Option list.

A	TA is relatively cheap
B	TA has a shelf life of 5 years
C	TA can be stored safely at room temperature
D	TA is widely available in most countries
E	none of the above.

Scenario 11.          Which, if any, of the following statements are true of the differences between the updated version of WHOT in 2017 and the 2012 version?

Option list.

A	TA to be used from the start of treatment of PPH
B	TA to be used only for cases with suspected or proven genital tract trauma
C	TA to be used as early as possible
D	TA not to be used > 5 hours after the birth
E	clearer instructions were given about the rate of administration