|
35 |
Diabetes & pregnancy. Jenny Myers |
|
36 |
EMQ. Headache |
|
37 |
EMQ. Surrogacy |
|
38 |
SBA. Kisspeptin |
35. Diabetes & pregnancy. Jenny Myers.
Jenny is Professor of Obstetrics & Maternal Medicine at Manchester University and a Consultant at St. Mary’s Hospital, the leading O&G teaching hospital in Manchester. She is an excellent teacher and an expert in diabetes, among other things. She is lovely lady, down-to-earth and very approachable; you will feel comfortable asking questions both for the exam and practice
36. EMQ. Headache.
|
1 |
abdominal migraine |
|
2 |
analgesia overuse, aka medication overuse |
|
3 |
bacterial meningitis |
|
4 |
benign intracranial hypertension |
|
5 |
BP check |
|
6 |
cerebral venous sinus thrombosis |
|
7 |
chest X-ray |
|
8 |
cluster |
|
9 |
impending eclampsia / severe PET |
|
10 |
malaria |
|
11 |
meningococcal meningitis |
|
12 |
methyldopa |
|
13 |
methysergide |
|
14 |
migraine |
|
15 |
MRI brain scan |
|
16 |
nifedipine |
|
17 |
nitrofurantoin |
|
18 |
pancreatitis |
|
19 |
sinusitis |
|
20 |
subdural haematoma |
|
21 |
subarachnoid haemorrhage |
|
22 |
tension |
|
23 |
ultrasound scan of the abdomen |
Scenario 1. A 45-year-old para 3 is admitted at 38 weeks by ambulance
with severe headache of sudden onset. She describes
it as “the worst I’ve ever had”. Which diagnosis needs to be excluded urgently?
Scenario 2. A 32-year-old para 1 has recently experienced headaches. They are worse on exercise, even mild exercise such as walking
up stairs. She experiences photophobia with the headaches. Which is the most likely diagnosis?
Scenario 3. A woman returns from a sub-Saharan area of Africa. She
develops severe headache, fever and rigors.
What diagnosis should particularly be in the minds of the attending doctors?
Scenario 4. A
woman at 37 weeks has s. They particularly occur at night without obvious triggers.
They occur every few days.
Scenario 5. A
primigravida has had s on a regular basis for many years. They occur most days,
are bilateral and are worse when she is stressed. What is the most likely diagnosis?
Scenario 6. A woman complains of recent headaches at 36 weeks. The history reveals that they started soon
after she began treatment with a drug prescribed by her GP. Which is the most
likely of the following drugs to be the culprit: methyldopa, methysergide, nifedipine
or nitrofurantoin?
Scenario 7. A woman is booked for Caesarean section and wishes regional
anaesthesia. She had severe headache due to dural tap after a previous
Caesarean section. She wants to take all possible steps to reduce the risk of
having this again. Which of epidural / spinal anaesthesia has the lower risk of
causing dural tap?
Scenario 8. A 25-year-old primigravida attends for her 20-week scan and
complains of headache which started two weeks before. There is no significant history.
The pain occurs behind her right eye and she describes it as severe and “stabbing”
in nature. The pain is so severe that she cannot sit still and has to walk
about. She has noticed that her right eye becomes reddened and “watery” during
the attack and her nose is “runny”. The attacks have no obvious trigger and
mostly occur a few hours after she has gone to sleep. The usually last about 20
minutes. She has no other symptoms. She smokes 20 cigarettes a day but does not
take any other drugs, legal or otherwise. What is the most likely diagnosis?
Scenario 9. A woman has a 5-year history of unilateral, throbbing
headache often preceded by nausea, visual disturbances, photophobia and
sensitivity to loud noise. What is the most likely diagnosis?
Scenario 10. A
primigravida is admitted at 38 weeks complaining of headache, abdominal pain
and a sensation of flashing lights. What would be the appropriate initial
investigation?
Scenario 11. A
woman with BMI of 35 attends for her combined Downs syndrome screening test.
She complains of pain behind her eyes. The pain is worst last thing at night before
she goes to sleep or if she has to get up in the night. She has noticed she has
noticed horizontal diplopia on several occasions. She has no other symptoms.
Examination shows papilloedema.
Scenario 12. A
grande multip of 40 years experienced sudden-onset, severe headache, vomited
several times and then collapsed, all within the space of 30 minutes. She is
admitted urgently in a semi-comatose state. Examination shows neck-stiffness
and left hemi-paresis.
Scenario 13. What did the MMR include as “red flags” for headache in pregnancy? These are not on the option list – you need
to dig them out of your head.
Option list.
|
A |
asthma |
↔ |
↑ |
↓ |
|
B |
developmental dysplasia of the hip in child |
↔ |
↑ |
↓ |
|
C |
diabetes |
↔ |
↑ |
↓ |
|
D |
Down’s syndrome in child |
↔ |
↑ |
↓ |
|
E |
hypertension |
↔ |
↑ |
↓ |
|
F |
ischaemic heart disease |
↔ |
↑ |
↓ |
|
G |
PET |
↔ |
↑ |
↓ |
|
H |
stroke |
↔ |
↑ |
↓ |
Scenario 15.
Which of the following drugs is contraindicated
in the prophylaxis of migraine in pregnancy?
Option list.
|
A |
amitriptyline
|
|
B |
ß-blockers |
|
C |
ergotamine |
|
D |
low-dose aspirin |
|
E |
pizotifen |
|
F |
pregabalin |
|
G |
tricyclic antidepressants |
|
H |
verapamil |
Scenario 16. Which, if any, of the following statements
is true about posterior reversible encephalopathy syndrome. This is not a true
EMQ as there may be > 1 true answer.
Option list.
|
A |
‘thunderclap’ headache is typical |
|
B |
‘handclap’ headache is typical |
|
C |
classically occurs in the early puerperium and
is recurrent |
|
D |
classically occurs in the early puerperium
and is not recurrent |
|
E |
arterial beading is typically seen on MRI |
|
F |
arterial beating is typically seen on MRI |
|
G |
arterial bleeding is typically seen on MRI |
|
H |
venous beading is typically seen on MRI |
|
I |
venous beating is typically seen on MRI |
|
J |
venous bleeding is typically seen on MRI |
|
K |
diagnosis requires lumbar puncture and evidence
of ↑
CSF pressure |
|
L |
treatment is with nimodipine |
Scenario 17. Which, if any, of the following
statements is true about reversible cerebral vasoconstriction syndrome. This is
not a true EMQ as there may be > 1 true answer.
Option list.
|
A |
‘thunderclap’ headache is typical |
|
B |
‘handclap’ headache is typical |
|
C |
classically occurs in the early puerperium
and is recurrent |
|
D |
classically occurs in the early puerperium
and is not recurrent |
|
E |
arterial beading is typically seen on MRI |
|
F |
arterial beating is typically seen on MRI |
|
G |
arterial bleeding is typically seen on MRI |
|
H |
venous beading is typically seen on MRI |
|
I |
venous beating is typically seen on MRI |
|
J |
venous bleeding is typically seen on MRI |
|
K |
diagnosis requires lumbar puncture and evidence
of ↑
CSF pressure |
|
L |
treatment is with nimodipine |
Questions from TOG article by Revell & Moorish. 2014. They
are open access.
Red flag features
for headaches include:
1. headache
that changes with posture True / False
2. associated
vomiting True / False
3. occipital
location True / False
4. associated
visual disturbance. True / False
Migraine is
classically,
5. bilateral.
True / False
6. pulsating.
True / False
7. aggravated
by physical exercise. True / False
With regard to
migraine headaches in pregnancy,
8. there
is an increase in the frequency of attacks without aura. True / False
9. women
who suffer from this have not been shown to have an increase in the risk of
pre-eclampsia. True / False
10. the
5HT1-receptor sumatriptan has been shown to be teratogenic. True / False
11. women
presenting with an aura for the first time are not at an increased risk of
intracranial disease. True / False
Posterior reversible
encephalopathy syndrome,
12. is
associated with an impairment of the autoregulatory mechanism which maintains
constant cerebral blood flow where there are blood pressure fluctuations. True / False
13. when
it is associated with pre-eclampsia, management should follow the pathway for
managing severe pre-eclampsia. True / False
With regard to
cerebral venous thrombosis,
14. the
incidence in western countries in pregnancy ranges from 1 in 2500 deliveries to
1 in 10 000 deliveries. True / False
15.
the greatest risk in pregnancy is mainly in the last four weeks. True / False
16. the
most common site is the sagittal sinus. True / False
17. a plain
computed tomography is a highly sensitive investigation. True / False
18. T2-weighted
magnetic resonance imaging has been shown to have limited value in diagnosis.
True / False
19. the
outcome is better when it is associated with pregnancy and the puerperium compared
to that occurring outside pregnancy. True / False
20. when
it occurs in pregnancy, it is a contraindication for future pregnancies. True / False
37. EMQ. Surrogacy.
Pick the best choice from the option list for each scenario.
Abbreviations.
CF: commissioning father
CM: commissioning mother
CPs: commissioning parents
PO: parental order
SM: surrogate mother
Option List.
a)
CM
b)
CF
c)
CPs
d)
SM
e)
Chairman of the HFEA
f)
Senior judge at the Children and Family Court
g)
traditional surrogacy
h)
gestational surrogacy
i)
HFEA
j)
SSAEW
k)
RCOG Surrogacy Sub-Committee
l)
false
m)
true
n)
none of the above
Scenario 1. List the
different types of surrogacy.
Scenario 2. “Gestational” surrogacy has better
“take-home-baby” rates than “traditional” surrogacy.
Scenario 3. There are approximately 1,000 surrogate
pregnancies per annum in the UK. True/False
Scenario 4. Which national body regulates surrogacy in
England?
Scenario 5. Privately-arranged
surrogate pregnancies are illegal and those involved are liable to up to 2
years in prison. True/False
Scenario 6. List the risks of surrogacy.
Scenario 7. Obstetricians
are legally obliged to take the CPs’ wishes into consideration in managing
pregnancy complications or problems.
Scenario 8. The psychological outcomes of surrogacy are
fully understood. True/False.
Scenario 9. The psychological outcomes of surrogacy are
more severe after traditional surrogacy.
True/False
Scenario 10. Who has the
right to arrange TOP if the fetus is found to have a major congenital
abnormality?
Scenario 11. A SM decides
at 10 weeks that she does not wish to be pregnant and arranges to have a TOP.
The CPs. hear about this and object strongly. To whom should they apply to have
the TOP blocked?
Scenario 12. A woman has
hysterectomy and BSO to deal with extensive endometriosis at the age of 30. She
marries two years later and her sister offers to act as surrogate. She
undergoes IVF and 4 embryos are created. One is transferred and a successful
pregnancy ensues. The baby is adopted by the woman and her husband. The 3
remaining embryos were frozen. Four years later the woman falls out with her
sister, but finds another surrogate and wishes to proceed with another pregnancy.
The sister says she does not want her eggs to be used and that the frozen
embryos should not be transferred. Does the sister have the legal right to
block the use of the embryos? Yes / No.
Scenario 13. A girl born
from donor sperm reaches the age of 16 and wishes to know the identity of her
genetic father. Does she have the right to this information? Yes / No.
Scenario 14. A girl born
from donor sperm reaches the age of 18 and wins a place at Oxford University to
read medicine. Does she have the legal right to get the donor to contribute to
her fees?
Yes / No.
Scenario 15. A PO is
active from the moment it is completed and signed by the relevant parties.
True/False
Scenario 16. A SM can
change her mind at any time and keep the child, even if the egg was not hers.
True/False
Scenario 17. The CPs can change their mind, leaving the SM
as the legal mother. True/False
Scenario 18. A SM’s husband is the legal father until
adoption is completed or a PO comes into force.
True/False
Scenario 19. A lesbian
couple in a stable, co-habiting relationship can be CPs and become the legal
parents of the child of a SM. True/False
Scenario 20. CPs are
likely to get faster legal status as the legal parents through application for
a PO rather than applying for adoption. True/False
38. SBA. Kisspeptin.
Pick the best statement about Kisspeptin.
Option list.
|
A |
is a pheromone released by the salivary glands during passionate
embraces |
|
B |
is a digestive enzyme released by the salivary glands
during passionate embraces |
|
C |
is a digestive enzyme found in human carnivores but not
vegetarians |
|
D |
is thought necessary for trophoblastic invasion and low
levels have been linked to miscarriage, recurrent miscarriage and ↑ risk of PET |
|
E |
is named after “Kiss me quick” chocolate |
|
F |
does not exist and this question is a very poor joke by
someone who should know better |
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