Tutorial 29 August

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29^th.  August   2022.

 

70	Role-play. Caesarean section on maternal request.
71	MCQ. The Coombs test
72	EMQ. The Term Breech Trial
73	SBA. Fetal origins of adult disease
74	EMQ. Kell antibodies

 

70. Role-play. Caesarean section on maternal request.

Candidate’s instructions.

You are a SpR5 in the antenatal clinic. Your consultant is feeling unwell and has gone to lie down.

The midwife has just seen a primigravid woman who has requested Caesarean section. She is healthy, with no significant medical history and the pregnancy has been normal. The gestation is 36 weeks, the head is engaged and the baby seems to be of an average size.

The midwife has done all the routine investigations and has asked you to see her to discuss the request for Caesarean section. It is your task to discuss her request as you would in a normal clinic.

 

71. MCQ. The Coombs test .

This is a question from the old days which I have not changed to EMQ/SBA format. The answers are ‘true’ or ‘false’, apart from questions d and e.         

a.  the direct test detects maternal IgM on fetal cells.

b.  is used in the investigation of thrombocytopenia.

c.   is positive in the baby with jaundice due to spherocytosis.

d.  who wrote: “A flea hath smaller fleas that on him prey…..”

e.  what was the rest of the verse?

f.   what connection has this verse with the Coomb’s test?

g.  the indirect Coomb’s test is used to detect antibodies in maternal serum.

h.  the direct test uses anti IgG serum.

 

72. EMQ. The Term Breech Trial .

Abbreviations.

BPAT:         breech presentation at term.

BPr:            breech presentation

Cb:              Caesarean birth.

Cs:              Caesarean section.

ECV:           external cephalic version.

IRTBT:        International Randomized Term Breech Trial

PIF:             RCOG’s Patient Information Leaflet: “Choosing to have a Caesarean section”.

TBD:           term breech delivery

TBT:            Term Breech Trial.

VB:             vaginal birth.

VBD:           vaginal breech delivery.

Question 1.       What is the approximate incidence of breech presentation at 28 weeks?

Option list.

A	3%
B	5%
C	7%
D	10%
E	12%
F	15%
G	20%

Question 2.       What is the approximate incidence of breech presentation at 32 weeks?

Option list. Use that from Q1.

Question 3.       What is the approximate incidence of breech presentation at 36  weeks?

Question 4.       What is the approximate incidence of breech presentation at 40 weeks?

Question 5.       What is the approximate incidence of breech presentation at 40 weeks after

successful ECV at 36 weeks? Don’t get bogged down looking for trick questions. You could argue that to be successful, ECV would need to ensure that all babies were cephalic at T, but the simplest meaning is that the baby was successfully turned at 36 weeks.

Option list.

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

Question 6.       What is the approximate incidence of cord prolapse with breech presentation in term

labour?

Option list.

A	1%
B	3%
C	5%
D	7%
E	10%
F	12%
G	15%
H	20%
I	none of the above

Question 7.       Which, if any, of the following are included in the RCOG’s PIF about the risks

associated with Cs?

Option list.

A	damage to bowel
B	damage to bladder
C	damage to ureter
D	damage to partner from fainting / falling
E	endometriosis
F	gestational trophoblastic disease
G	hysterectomy
H	miscarriage
I	placental accreta
J	placenta previa
K	postnatal depression
L	PPH
M	scar dehiscence
N	scar herniation
O	scar pregnancy
P	stillbirth
Q	thromboembolism

Question 8.       What are the 3 key questions in the RCOG’s PIF that patients are advised to ask?

Question 9.       Which, if any, of the following were in the main conclusions of the Term Breech Trial?

Option list.

A	stillbirths were significantly fewer with planned C section
B	neonatal mortality was reduced significantly by planned C section
C	neonatal morbidity was reduced significantly by planned C section
D	serious neonatal morbidity was reduced significantly by planned C section
E	perinatal mortality was reduced significantly by planned C section
F	perinatal morbidity was reduced significantly by planned C section
G	serious perinatal morbidity was reduced significantly by planned C section
H	none of the above

Question 10.    Which, if any, of the following were in the main conclusions of the follow up at 2 years

of the children in the Term Breech Trial?

Option list.

A	neonatal mortality was reduced significantly by planned C section
B	neonatal morbidity was reduced significantly by planned C section
C	planned C section reduced the risk of child death up to 2 years
D	planned C section reduced the risk of child morbidity up to 2 years
E	planned C section improved child neurodevelopment at 2 years of age
F	none of the above

Question 11.    Which, if any, of the following were included in the conclusions of the Premoda Trial?

Option list.

A	fetal mortality was reduced by planned cs
B	neonatal mortality was reduced by planned cs
C	neonatal morbidity was reduced by planned cs
D	surgeons’ sleep patterns were improved planned cs
E	Cs should be offered as superior to planned vaginal delivery even in expert centres
F	VBD is a safe option in centres where it is commonly practised and strict criteria are met

Question 12.    Which, if any, of the following are listed as contraindications to VBD in GTG20a.

Option list.

F	maternal height < 1.6 metres
G	maternal BMI > 30
C	gestation < 36 weeks
A	failed ECV at 36 weeks
B	reversion to breech presentation after successful ECV at 36 weeks
D	estimated fetal weight > 3.5 kg.
E	estimated fetal weight <25th. centile.
H	hyperextended fetal neck
I	footling presentation

 

73. SBA. Fetal origins of adult disease .

Abbreviations.

ADHD:  attention-deficit, hyperactivity disorder

Lead in. These questions relate to disease in adults resulting from events during fetal, infant and child development.

Scenario 1.   What eponymous title is given to the concept that adverse intra-uterine conditions

predispose to the development of disease in adulthood?

Option List                              

A	the Barker hypothesis
B	the Baker’s dozen
C	the Broadbank theory
D	PIPAD: Placental Insufficiency Programmes Adult Disease
E	SIMCARD: Stop In-utero Malnutrition to Conquer Adult-resulting Disease

Scenario 2.   Which other term is used for the concept that adverse intra-uterine conditions

 predispose to the development of disease in adulthood?

Option List

A	FDAD: fetal determination of adult disease
B	FIAD:   fetal influences on adult disease
C	FIDAD: fetal and infancy determinants of adult disease
D	FIGO:   fetal influences on genomic outcomes
E	FP:       fetal programming

Scenario 3.   Which of the following is thought to increase the risk of adult disease?

Option List

A	low birthweight (LBW)
B	LBW followed by poor weight gain in infancy and childhood
C	LBW followed by poor weight gain in infancy but above-average weight gain in childhood
D	above-average birthweight (AABW)
E	AABW followed by poor weight gain in infancy but above-average weight gain in childhood
F	AABW followed by above-average weight gain in infancy and childhood

Scenario 4.   Which adult diseases are generally believed to be more likely in relation to adverse

influences on the fetus, infant and child.

Diseases.

A	asthma
B	chronic bronchitis
C	coronary heart disease
D	diabetes type I
E	diabetes type 2
F	hypertension
G	Mendelson’s syndrome
H	Stroke

Scenario 5.   What adult condition has been linked to raised maternal c-reactive protein levels?

Option List                              

A	asthma
B	ADHD
C	autism
D	inflammatory bowel disease
E	schizophrenia

 

74. EMQ. Kell antibodies  .

Abbreviations.

∆OD₄₅₀:      spectrophotometric measurement of deviation in optical density at wavelength 450 nm.

FMM:         feto-maternal medicine.

HDFN:        haemolytic disease of the fetus and newborn.

MCAPSV:   middle cerebral artery peak systolic velocity.

RBC:           red blood cell.

Scenario 1.        Which of the following alloantibodies is the most common cause of significant HDFN?

Option list.

A	anti-D
B	anti-C
C	anti-c
D	anti-e
E	Duffy: Fya
F	Duffy: Fyb
G	Kell
H	Kidd: Jka
I	Kidd: Jkb

Scenario 2.        What is the 2^nd. most common cause of significant HDFN?

Scenario 3.        What is the 3^rd. most common cause of significant HDFN?

Scenario 4.        Which of the following is true in relation to the Kell antigen?

Option list.

A	it is named after Mrs. Kelleher who was found to have antibodies to it in 1946
B	it is named after Gene Kelly, the American actor, dancer and singer as the research group who found the antigen were big fans
C	there are > 50 significant variants of the Kell antigen
D	Kell antibodies are mainly IgA
E	Kell antibodies are mainly IgM
F	none of the above

Scenario 5.        What proportion of the Caucasian population is K +ve?

Option list.

A	1%
B	5%
C	9%
D	15%
E	25%
F	33%
G	57%
H	none of the above

Scenario 6.        Can the Kell antigen be detected using cffDNA in maternal serum.  True / False.

Scenario 7.        Anti-K is thought to occur mainly as a result of feto-maternal transfusion of Kell +ve

cells during pregnancy and delivery. True / False.

Scenario 8.        Kell HDFN resulting from transfusion of Kell +ve blood is thought to produce more

severe HDFN than that resulting from feto-maternal transfusion. True / False.

Scenario 9.        Which of the following statements is true in relation to anti-Kell antibodies in a Kell-

negative mother with a Kell +ve pregnancy?

Option list.

A	HDND is mainly due to haemolysis of fetal RBC
B	HDND is mainly due to haemolysis of fetal & neonatal RBC
C	HDND is mainly due to haemolysis of neonatal RBC
D	HDND is mainly due to sequestration of fetal RBC
E	HDND is mainly due to sequestration of fetal & neonatal RBC
F	HDND is mainly due to sequestration of neonatal RBC
G	HDND is mainly due to suppression of fetal erythroid progenitor cells
H	HDND is mainly due to suppression of neonatal erythroid progenitor cells
I	none of the above

Scenario 10.     Which of the following statements is true in relation to antenatal detection of HDFN

due to anti-K antibodies?

Option list.

A	the threshold for significant HDFN is a titre of 1 in 4
B	the threshold for significant HDFN is a titre of 1 in 8
C	the threshold for significant HDFN is a titre of 1 in 16
D	the threshold for significant HDFN is a titre of 1 in 32
E	the threshold for significant HDFN is a titre of 1 in 64
F	the threshold for significant HDFN is a titre of 1 in 128
G	the threshold for significant HDFN is a titre of 1 in 256
H	none of the above

Scenario 11.     Which of the following statements is true in relation to antenatal detection of HDFN

due to anti-K antibodies?

Option list.

A	the threshold for significant HDFN is a level > 2 iu/L.
B	the threshold for significant HDFN is a level > 4 iu/L.
C	the threshold for significant HDFN is a level > 7.5 iu/L.
D	the threshold for significant HDFN is a level > 10 iu/L.
E	the threshold for significant HDFN is a level > 15 iu/L.
F	the threshold for significant HDFN is a level > 25 iu/L.
G	the threshold for significant HDFN is any level if anti-E is also present.
H	none of the above

Scenario 12.     Which, if any, of the following statements are true in relation to referral to a FMM

expert when Kell antibodies are detected?

Option list.

A	the threshold for referral is a level of anti-K > 2 iu/L.
B	the threshold for referral is a level of anti-K > 4 iu/L.
C	the threshold for referral is a level of anti-K > 7.5 iu/L.
D	the threshold for referral is a level of anti-K > 10 iu/L.
E	the threshold for referral is a level of anti-K > 15 iu/L.
F	the threshold for referral is a level of anti-K > 25 iu/L.
G	the threshold for referral is any level of anti-K.
H	the threshold for referral is any level of anti-K if anti-E is also present.
I	none of the above

Scenario 13.     Which of the following statements is true in relation to the threshold for antenatal

diagnosis of significant HDFN due to anti-K when using measurement of MCAPSV?

Option list.

A	MoM > 1.25
B	MoM > 1.50
C	MoM > 1.75
D	MoM > 2.00
E	MoM > 2.50
F	MoM > 3.00
G	none of the above

Scenario 14.     Which of the following statements is true in relation to the threshold for antenatal

diagnosis of significant HDFN due to anti-K when using measurement of ∆OD₄₅₀?

Option list.

A	MoM > 1.25
B	MoM > 1.50
C	MoM > 1.75
D	MoM > 2.00
E	MoM > 2.50
F	MoM > 3.00
G	none of the above

Scenario 15.     Which, if any, of the following statements are true in relation to the numbers of

reticulocytes in cord blood in moderate to severe HDFN due to anti-K antibodies?

Option list.

A	the numbers are decreased
B	the numbers are increased
C	the numbers are normal
D	none of the above

Scenario 16.     Which, if any, of the following statements are true in relation to the numbers of

erythroblasts in cord blood in moderate to severe HDFN due to anti-K antibodies?

Option list.

A	the numbers are decreased
B	the numbers are increased
C	the numbers are normal
D	none of the above

Scenario 17.     Which, if any, of the following statements are true in relation to the level of bilirubin

in cord blood in moderate to severe HDFN due to anti-K antibodies?

Option list.

A	it is decreased
B	it is increased
C	it is greatly increased
D	none of the above

Scenario 18.     Which, if any, of the following are true in relation to King Henry VIII and Kell?

Option list.

A	Kell may have been the cause of his subfertility
B	He may have had the McLeod syndrome
C	He may have inherited the Kell antigen from Jacquetta Woodville
D	The Kell antigen may have explained his passion for jousting
E	The Kell antigen may have explained his passion for extramarital dalliance

 

The TOG questions for the Gajjar article can be found  here.

They are open access, which allows me to reproduce them.

Regarding Kell alloimmunisation in pregnancy,

1      the amniotic fluid bilirubin level correlates well with the degree of fetal anaemia.     True / False

2      previous obstetric history does not reliably predict outcome.                               True / False

3      the incidence in the obstetric population is approximately 1–2 per 1000.                        True / False

4      prophylaxis is available.                                                                                                 True / False

5      the relationship between fetal middle cerebral artery peak systolic velocity (MCA-PSV) and haemoglobin concentration is poor.                                                                       True / False

6      anti-Kell antibodies cause fetal anaemia via the suppression of erythropoiesis rather than red cell destruction.                                                                                                                    True / False

With regard to maternal anti-Kell antibody screening,

7      if the father of the fetus is Kell antigen positive, the fetus is likely to be affected with severe HDFN.                                                                                                                  True / False

8      where the father is heterozygous for Kell, there is a 50% chance of the fetus carrying the Kell antigen on its fetal red cells.                                                                                True / False

9      anti-Kell antibodies stimulated by transfusion are known to affect the fetus to the same degree as those stimulated from a previous pregnancy.                                                              True / False

Transfusion seems to produce less severe disease.

10    where the critical titre of anti-Kell antibodies has been reached in the maternal serum, amniocentesis for spectral analysis of amniotic fluid is a reliable means of establishing the degree and severity of fetal anaemia.                                                                            True / False