Tutorial 8th. December 2022

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8 December 2022.                                                

 

36	Structured conversation. Labour ward scenario
37	EMQ. Group B streptococcus
38	SBA. Appendicitis in pregnancy
39	EMQ. Toxoplasmosis
40	SBA. UKOSS

 

36.         Labour ward scenario.

You are the registrar on duty and responsible for the labour and gynae wards. You have just had the handover. Your task is to discuss the overall management of the wards with the examiner, to prioritise the patients and decide the allocation of staff to care for them.

This station was written for the first tutorial I ran for the OSCE exam when it was introduced more than 20 years ago. There are phrases and concepts that reveal this distant origin, but I have retained them for nostalgic reasons. I ran the tutorial on a Sunday afternoon when I was on-call and using what was happening on the labour and gynae wards that day. You won’t be asked about gynae patients in a labour ward station!

Labour Ward. Sunday 13.00 hours.

1	Mrs JH	Primigravida. T+8. In labour. 6 cms.
2	Mrs AH	Primigravida at T. In labour. 5 cms.
3	Mrs. BH	Para 2. 30 days post delivery. 2ry. PPH > 1,000 ml. Hb. 9.3.
4	Mrs SB	Primigravida. 32/52 gestation. Admitted 30 minutes ago. Abdominal pain + 200 ml. bleeding. Nephrostomy tube in situ - not draining since this morning. Low placenta on 20 week scan.
5	Mrs KW	Para 1. In labour. Cx. 5 cm. Ceph at spines.
6	Mrs KT	Para 0+1. 38 weeks. SROM. Ceph 2 cm. above spines. Clear liquor.
7	Mrs TB	Para 1. T+4. Clinically big baby. Cx fully dilated for 1 hour. Early decelerations.
8	Mrs RJ	Primigravida. Epidural. RIF pain. Cx fully dilated for 1 hour. Shallow late decelerations. OT position. Distressed ++. BP /105. ++ protein. Urine output 50 ml in past 4 hours.
9	Mrs KC	Transfer from ICU. 13 days after delivery of 32 week twins. Laparotomy on day 7 for pelvic pain and fever. Infected endometriotic cyst removed. IV antibiotics changed to oral.

Gynaecology ward.

8 major post-operative cases who have been seen on the morning ward round and are stable. The husband of a patient who had Wertheim's hysterectomy on the Friday was asking to see a doctor for a report on the operation.

1	Mrs JB	10 week incomplete miscarriage. Hb. 10.8. Moderate fresh bleeding.
2	Ms AS	19 years old. Nulliparous. Just admitted with left iliac fossa pain. Scan shows unilocular 5 cm. ovarian cyst.

Medical staff:

Consultant at home. Registrar - you.

Senior House Officer with 12 months experience.

Registrar in Anaesthesia.

Consultant Anaesthetist on call at home.

Midwifery staff:

Senior Sister.     Trained to take theatre cases. Able to site IV infusions and suture episiotomies and tears.

3 staff midwives. 1 trained to take theatre cases. Two able to site IV infusions.

1 Community midwife looking after Mrs. KW.

2 Pupil Midwives.

 

37.         EMQ. Group B streptococcus.

Abbreviations.

EOGBSD:      early onset GBSD.

GBSD:           GBS disease.

GBSIP:           GBS in pregnancy.

LOGBSD:       late-onset GBSD.

UTI:               urinary tract infection.

Option list 1.

A	< 5%
B	10%
C	15%
D	20%
E	30%
F	40%
G	50%
H	>50%

Question 1.        Which condition is of greatest significance in relation to GBSIP?

Option list.

A	chorio-amnionitis
B	early-onset GBS disease in the neonate
C	late -onset GBS disease in the neonate
D	maternal urinary tract infection
E	maternal pneumonia
F	puerperal endometritis
G	stillbirth
H	none of the above

Question 2.        What is the incidence of the condition of greatest significance in relation to GBSD?

Use Option list 1.

Question 3.        Approximately how common is GBS colonisation in adults? Use Option List 1.

Question 4.             What is the approximate rate of vertical transmission in cases of maternal GBS

colonisation?

Use Option List 1

Question 5.             Approximately how many neonates will develop EOGBSD in cases of maternal GBS colonisation?

Use Option List 1

Question 6.        What is the first statement in the executive summary section of GTG36?

Option list.

A	all pregnant women should be provided with an appropriate PIF
B	all pregnant women should be given web addresses for GBS information website
C	clinicians should know the risk factors for EOGBSD
D	clinicians should know the relative risk for EOGBSD associated with the main risk factors
E	universal bacteriological screening is not recommended

Question 7.        What is the second statement in the executive summary section of GTG36?

Option list.

A	all pregnant women should be provided with an appropriate PIF
B	all pregnant women should be given web addresses for GBS information website
C	clinicians should know the risk factors for EOGBSD
D	clinicians should know the relative risk for EOGBSD associated with the main risk factors
E	universal bacteriological screening is not recommended

Question 8.        What is the third statement in the executive summary section of GTG36?

Option list.

A	all pregnant women should be provided with an appropriate PIF
B	all pregnant women should be given web addresses for GBS information website
C	clinicians should know the risk factors for EOGBSD
D	clinicians should know the relative risk for EOGBSD associated with the main risk factors
E	universal bacteriological screening is not recommended

Question 9.        What risk factors for EOGBSD are listed in GTG36?

Question 10.    A woman was a GBS carrier in pregnancy. What is the risk of recurrence?

Use Option List 1

Question 11.         What management options should be offered to a pregnant woman with a history of a previously affected baby but no evidence of GBS in the current pregnancy? This is not a true EMQ as there may be > 1 correct answer.

Option list.

A	inform her that the risk of being a carrier in this pregnancy is 25%
B	IAP without screening
C	IAP if screening shows bowel colonisation, but not if it is absent
D	IAP if screening shows genital tract colonisation, but not if it is absent
E	IAP if screening shows urinary tract colonisation, but not if it is absent
F	IAP if screening shows any GBS colonisation
G	screening for GBS at around 36 weeks, with IAP if testing is +ve

Question 12.         What management options should be offered to a pregnant woman with a history of GBS carriage in a previous pregnancy but no EOGBSD or LAGBSD and no evidence of it in the current pregnancy? This is not a true EMQ as there may be > 1 correct answer.

Option list.

A	inform her that the risk of being a carrier in this pregnancy is 25%
B	IAP without screening
C	IAP if screening shows bowel colonisation, but not if it is absent
D	IAP if screening shows genital tract colonisation, but not if it is absent
E	IAP if screening shows urinary tract colonisation, but not if it is absent
F	IAP if screening shows any GBS colonisation
G	screening for GBS at around 36 weeks, with IAP if testing is +ve

Question 13.         Which, if any, of the following statements are true in relation to screening for GBS in pregnancy?

Option list.

A	screening should be done 1-3 weeks before the ADD
B	screening should be done 2-4 weeks before the ADD
C	screening should be done 3-5 weeks before the ADD
D	screening should be done 4-6 weeks before the ADD
E	screening should be done 4-6 weeks before the ADD
F	screening should not be offered

Question 14.    Which, if any, of the following statements is true in relation to screening for GBS in

twin pregnancy?

Option list.

A	screening should be done 1-3 weeks before the ADD
B	screening should be done 2-4 weeks before the ADD
C	screening should be done 3-5 weeks before the ADD
D	screening should be done 4-6 weeks before the ADD
E	screening should be done 4-6 weeks before the ADD
F	screening should not be offered

Question 15.    Which, if any, of the following statements is true in relation to screening for GBS?

Option list.

A	oral, rectal & vaginal swabs should be taken and an MSU
B	rectal & vaginal swabs should be taken
C	rectal & vaginal swabs should be taken and an MSU
D	a single swab can be used, swabbing orally then vaginally, then rectally
E	a single swab can be used, swabbing vaginally, then rectally
F	none of the above

Question 16.    Which, if any, of the following statements are true in relation to transport of swabs for

GBS?

Option list.

A	swabs should be transported to the laboratory ASAP
B	swabs should be transported to the laboratory refrigerated
C	swabs should be transported in a non-nutrient medium
D	sways should be transported in a nutrient-enhanced medium
E	Amies medium is suitable
F	Stuart medium is suitable
G	blood agar is suitable

Question 17.         Which, if any, of the following statements are true in relation to processing of swabs for GBS?

Option list.

A	processing should be done ASAP
B	specimens should be refrigerated if processing cannot be done immediately
C	specimens should be stored at a temperature lower than –10oC  if processing cannot be done immediately
D	testing should be done using an enriched culture medium
E	testing should be done using a cultured medium

Question 18.    Which, if any, of the following statements is true in relation to screening for GBS in

twin pregnancy?

Option list.

A	screening should be done 30-32 weeks
B	screening should be done 31-33 weeks
C	screening should be done 32-34 weeks
D	screening should be done 33-35 weeks
E	screening should be done 34-36 weeks
E	screening should be done 35-37 weeks
E	screening should be done 36-38 weeks
F	screening should not be offered

Question 19.    What does GTG say about screening for GBS on maternal request when there are no

factors indicating increased risk?

Option list.

A	maternal request is not an indication for screening
B	refer her to a hospital with a policy of offering screening on request
C	screening should be offered it still desired after explanation of the pros and cons and that it is not recommended
D	the request should be respected and screening offered
E	none of the above

Question 20.    Which, if any, of the following would be appropriate management of a pregnant

woman with GBS UTI?

Option list.

A	offer IAP
B	repeat the MSU
C	treat the UTI and arrange appropriate follow-up and GBS screening
D	treat the UTI, arrange appropriate follow-up and offer IAP
E	none of the above

Question 21.    What advice does ACOG797 give about the use of clindamycin for GBS UTI infection.

Option list.

A	it should be the 1st. choice for treatment in those who are not allergic to it
B	it should be the 1st. choice for treatment in those who are allergic to penicillin
C	it should only be used intravenously for treatment of urinary tract infection
D	it should not be used for urinary tract infection
E	it should be used, like other antibiotics, based on the sensitivity of the infecting organism

Question 22.    Which, if any, of the following would be appropriate management of a pregnant

woman with GBS on a vaginal or rectal swab?

Option list.

A	offer IAP
B	repeat the swab
C	treat the infection and arrange appropriate follow-up and GBS screening
D	treat the infection, arrange appropriate follow-up and offer IAP
E	none of the above

Question 23.    Which, if any, of the following statements are correct about induction of labour in

women who are carriers of GBS?

Option list.

A	amniotomy is the preferred method
B	membrane sweeping is contra-indicated
C	vaginal PGE2 is the preferred method
D	an i.v. antibiotic should be given with the start of the process
E	none of the above

Question 24.    A woman with no risk factors for GBS goes into preterm labour. Which, if any, of the

following statements are correct?

Option list.

A	GBS screening should be done with PCR or other ‘near-patient’ test
B	IAP should be offered
C	IAP should not be offered unless clinical evidence of infection appears
D	tocolytics should be offered
E	none of the above

Question 25.    A woman with no risk factors for GBS has PPROM. Which, if any, of the following

statements are correct?

Option list.

A	GBS screening should be done
B	IAP should be offered immediately
C	IAP should be offered when labour ensues or is induced
D	IOL should be offered
E	none of the above

Question 26.    In which of the following situations is polymerase chain reaction or other ‘near-

patient’ testing recommended in relation to GBS?

Option list.

A	women admitted with SROM whose GBS status is unknown
B	women treated for GBS infection in pregnancy admitted in preterm labour
C	women for whom C section is planned but go into premature labour
D	unbooked patients admitted in labour
E	unbooked patients admitted with SROM
F	none of the above

Question 27.    A woman who is a know GBS carrier wishes to use a birthing pool. Which, if any, of the

following statements are correct?

Option list.

A	use of a birthing pool is contraindicated
B	use of a birthing pool is not contraindicated
C	use of a birthing pool is not contraindicated so long as appropriate IAP is given
D	use of a birthing pool is acceptable, but the water must contain an antiseptic in a concentration known to kill > 99.9% of all known bacteria and viruses
E	tell her not to be stupid
F	none of the above

Question 28.    A woman in labour has a temperature of 38.4⁰C. Which of the following is correct?

Option list.

A	IAP should be offered
B	amoxicillin should be offered unless she is allergic to penicillin
C	amoxicillin + metronidazole should be offered unless she is allergic to penicillin
D	a cephalosporin should be offered
E	a cephalosporin + metronidazole should be offered
F	none of the above

Question 29.    Which, if any, of the following statements are true in relation to GBS and prematurity.

Option list.

A	IAP should be offered
B	premature babies are less likely to develop EOGBSD than term babies
C	premature babies are just as likely to develop EOGBSD as term babies
D	premature babies are four times more likely to develop EOGBSD than term babies
E	premature babies are ten times more likely to develop EOGBSD  than term babies
F	premature babies are less likely to die of EOGBSD than term babies
G	premature babies are just as likely to die of EOGBSD as term babies
H	premature babies are four times more likely to die of EOGBSD than term babies
I	premature babies are ten times more likely to die of EOGBSD than term babies

Question 30.    A GBS carrier has PPROM. Which, if any, of the following statements are correct?

Option list.

A	IAP should be offered immediately
B	IAP should be offered when labour starts
C	IAP should not be offered
D	erythromycin should be offered immediately if not contraindicated
E	erythromycin should be offered when labour starts if not contraindicated
F	erythromycin should not be offered
G	IOL should be offered ASAP
H	IOL should not be offered
I	labour should be augmented as soon as contractions start

Question 31.    A GBS carrier goes into premature labour Which, if any, of the following statements

are correct?

Option list.

A	IAP should be offered immediately
B	IAP should be offered when contractions start
C	IAP should not be offered
D	augmentation of labour should be offered ASAP
E	augmentation of labour  should not be offered
F	labour should be augmented as soon as contractions start

Question 32.    A woman whose GBS carrier status is negative has PPROM. Which, if any, of the

following statements are correct?

Option list.

A	expectant management for up to 24 hours is acceptable
B	expectant management for up to 48 hours is acceptable
C	IAP should be offered immediately
D	IAP should be offered when contractions start
E	IAP should not be offered
F	immediate IOL is acceptable
G	IOL should not be delayed > 24 hours if labour does not ensue
H	IOL should not be offered
I	labour should be augmented as soon as contractions start

Question 33.    A woman whose GBS carrier status is unknown has PPROM. Which, if any, of the

following statements are correct?

Option list.

A	expectant management for up to 24 hours is acceptable
B	expectant management for up to 48 hours is acceptable
C	IAP should be offered immediately
D	IAP should be offered when contractions start
E	IAP should not be offered
F	immediate IOL is acceptable
G	IOL should not be delayed > 24 hours if labour does not ensue
H	IOL should not be offered
I	labour should be augmented as soon as contractions start

Question 34.    A GBS carrier has SROM at 38 weeks. Which, if any, of the following statements are

correct?

Option list.

A	IAP should be offered immediately
B	IAP should be offered when contractions start
C	IAP should not be offered
D	IOL should be offered ASAP
E	IOL should not be offered
F	labour should be augmented as soon as contractions start

Question 35.    A GBS carrier goes into labour at 38 weeks. Which, if any, of the following statements

are correct?

Option list.

A	IAP should be offered immediately
B	IAP should be offered when contractions start
C	IAP should not be offered
D	augmentation of labour should be offered ASAP
E	augmentation of labour  should not be offered
F	labour should be augmented as soon as contractions start

Question 36.    A woman whose GBS carrier status is negative has SROM at 38 weeks. Which, if any,

of the following statements are correct?

Option list.

A	expectant management for up to 24 hours is acceptable
B	expectant management for up to 48 hours is acceptable
C	IAP should be offered immediately
D	IAP should be offered when contractions start
E	IAP should not be offered
F	immediate IOL is acceptable
G	IOL should not be delayed > 24 hours if labour does not ensue
H	IOL should not be offered
I	labour should be augmented as soon as contractions start

Question 37.    A woman whose GBS carrier status is unknown has SROM at 38 weeks. Which, if any,

of the following statements are correct?

Option list.

A	expectant management for up to 24 hours is acceptable
B	expectant management for up to 48 hours is acceptable
C	IAP should be offered immediately
D	IAP should be offered when contractions start
E	IAP should not be offered
F	immediate IOL is acceptable
G	IOL should not be delayed > 24 hours if labour does not ensue
H	IOL should not be offered
I	labour should be augmented as soon as contractions start

Question 38.    What vaginal cleansing is recommended in GTG36 for women known to be colonised

with GBS to reduce fetal transmission in labour and delivery?

Option list.

A	aqueous chlorhexidine 1%
B	povidone-iodine 1%
C	acetic acid 1%
D	aqueous bicarbonate of soda 1%
E	none of the above.

Question 39.    Which antibiotic / antibiotic combination is the 1^st. choice for IAP, assuming no allergy

or other contraindication?

Option list.

A	a cephalosporin
B	a cephalosporin + clavulanic acid
C	a cephalosporin + metronidazole
D	a cephalosporin + streptomycin
E	amoxicillin
F	amoxicillin + clavulanic acid
G	amoxicillin + metronidazole
H	amoxicillin + streptomycin
I	benzylpenicillin
J	benzylpenicillin + clavulanic acid
K	benzylpenicillin + metronidazole
L	benzylpenicillin + streptomycin
M	tetracycline
N	tetracycline + clavulanic acid
O	tetracycline + metronidazole
P	tetracycline + streptomycin
Q	none of the above

Question 40.    Which antibiotic / antibiotic combination is the 2^nd. choice for IAP, assuming no allergy

or other contraindication?

Option list.

A	a cephalosporin
B	a cephalosporin + clavulanic acid
C	a cephalosporin + metronidazole
D	a cephalosporin + streptomycin
E	amoxicillin
F	amoxicillin + clavulanic acid
G	amoxicillin + metronidazole
H	amoxicillin + streptomycin
I	benzylpenicillin
J	benzylpenicillin + clavulanic acid
K	benzylpenicillin + metronidazole
L	benzylpenicillin + streptomycin
M	tetracycline
N	tetracycline + clavulanic acid
O	tetracycline + metronidazole
P	tetracycline + streptomycin
Q	none of the above

Question 41.    How should babies at risk of EOGBSD whose mothers have had adequate IAP be

monitored for signs of infection?

Option list.

A	routine monitoring is all that is required
B	they should be checked at birth for signs of infection
C	their vital signs should be checked hourly for 12 hours
D	their vital signs should be checked hourly for 24 hours
E	their vital signs should be checked hourly for 48 hours
F	their vital signs should be checked 4 hourly for 12 hours
G	their vital signs should be checked 4 hourly for 24 hours
H	their vital signs should be checked 4 hourly for 48 hours
I	their vital signs should be checked at 0, 1 & 2 hours, then hourly until 12 hours
J	their vital signs should be checked at 0, 1 & 2 hour,s then hourly until 24 hours
K	their vital signs should be checked at 0, 1 & 2 hours, then hourly until 48 hours
L	their vital signs should be checked at 0, 1 & 2 hours, then 2 hourly until 12 hours
M	their vital signs should be checked at 0, 1 & 2 hours, then 2 hourly until 24 hours
N	their vital signs should be checked at 0, 1 & 2 hours, then 2 hourly until 48 hours
O	their vital signs should be checked at 0, 1 & 2 hours, then 4 hourly until 12 hours
P	their vital signs should be checked at 0, 1 & 2 hours, then 4 hourly until 24 hours
Q	their vital signs should be checked at 0, 1 & 2 hours, then 4 hourly until 48 hours
R	none of the above

Question 42.         What antibiotic treatment should be provided for babies with signs of EOGBSD?

Option list.

A	benzylpenicillin within 1 hour of birth
B	benzylpenicillin within 4 hours of birth
C	benzylpenicillin + gentamycin within 1 hour of birth
D	benzylpenicillin + gentamycin within 4 hours of birth
E	benzylpenicillin  + metronidazole within 1 hour of birth
F	benzylpenicillin  + metronidazole within 4 hours of birth
G	benzylpenicillin + streptomycin within 1 hour of birth
H	benzylpenicillin  + streptomycin within 4 hours of birth
I	none of the above

Question 43.    A woman is noted to be pyrexial in labour, temperature = 38.4^OC. What antibiotic

therapy, if any, should be provided, assuming she has no drug allergies?

Option list.

A	benzyl penicillin
B	amoxicillin
C	amoxicillin + clavulanic acid
D	broad spectrum antibiotic that covers GBS and is in accordance with the local antibiotic advice.
E	a cephalosporin
F	clindamycin
G	quinolone antibiotic that covers GBS and is in accordance with the local antibiotic advice.
H	none of the above

Question 44.    A woman is found to have GBS colonisation but declines IAP. Which, if any, of the

following are appropriate?

Option list.

A	advise her that she should stay in hospital for at least 48 hours so the baby can be monitored
B	ask her to transfer to another hospital if she won’t take your advice re the GBS protocol
C	explain the rationale of the policy relating to IAP and maternal GBS colonisation
D	get the hospital lawyer to ask the Court of Protection to appoint a Deputy to authorise IAP.
E	give her a good slapping
F	tell her to think about the baby, not herself

Question 45.    What possible adverse effects of IAP are discussed in GTG36?

Option list.

A	anaphylaxis
B	antibiotic resistance
C	disturbance of neonatal microbiome
D	NEC
E	asthma in children
F	cerebral palsy in children
G	impaired functional development in children
H	inflammatory bowel disease in children
I	schizophrenia in adolescents

Question 46.    What advice should be given about breastfeeding?

Option list.

A	it should be encouraged
B	it should be encouraged but withheld during administration of IAP
C	it should be encouraged but withheld during administration of IAP and the week after
D	it is contraindicated
E	none of the above.

Question 47.         Why is it useful to remember 50% in relation to EOGBSD? This is not a true EMQ as there may be > 1 correct answer.

Option list.

A	it is the chance of getting the correct answer with ‘intelligent guessing’
B	it is the risk of carrier status in pregnancy
C	It is the risk of recurrence of carrier status in the next pregnancy
D	it is the risk of carrier status in the partner
E	it is the risk of vertical transmission if the mother is colonised
F	It is the risk of EOGBSD if vertical transmission occurs
G	mortality rates before modern screening and IAP were up to 50%
H	none of the above.

 

38.         SBA. 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.  Answer False / True

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.

 

39.         EMQ. Toxoplasmosis.

Abbreviations.

cTg:             congenital toxoplasmosis.

TgIgG:        Toxoplasmosis immunoglobulin G.

TgIgM:       Toxoplasmosis immunoglobulin M.

Question 1.             Which, if any, of the following are true in relation to the organism causing

toxoplasmosis.

Option list.

A	it is Toxoplasma giardia
B	it is Toxoplasma gondi
C	it is Toxoplasma gondii
D	it is Toxoplasma gondola
E	it is Toxoplasma gung-ho
F	none of the above

Question 2.        Approximately what proportion of the UK pregnant population shows evidence of

previous Tg infection?

Option list.

A	< 10%
B	10%
C	20%
D	30%
E	40%
F	50%
G	> 50%

Question 3.        When is maternal infection believed to be of greatest risk to the fetus?

Option list.

A	peri-conceptually
B	1st. trimester
C	2nd. trimester
D	3rd. trimester
E	during vaginal birth
F	in the puerperium
G	in the puerperium if breastfeeding
H	none of the above

Question 4.        Which, if any,  of the following are true with regard to when tgIgG is detectable after

1ry maternal infection?

Option list.

A	2 weeks
B	4 weeks
C	2 months
D	3 months
E	6 months
F	none of the above

Question 5.        Which, if any,  of the following are true with regard to when TgIgM is detectable after

1ry maternal infection?

Option list.

A	2 weeks
B	4 weeks
C	2 months
D	3 months
E	6 months
F	none of the above

Question 6.        Which, if any,  of the following are true with regard to avidity testing for Tg?

Option list.

A	avidity testing is of little use
B	avidity testing requires expert advice
C	avidity < 30% indicates infection in the previous 3 months
D	avidity < 30% indicates infection in the previous 6 months
E	avidity < 30% indicates infection in the previous 9 months
F	avidity > 40% indicates infection more than 3 months previously
G	avidity > 40% indicates infection more than 6 months previously
H	avidity > 40% indicates infection more than 9 months previously
I	none of the above

Question 7.        Which, if any,  of the following are true with regard to confirmation of fetal infection?

Option list.

A	avidity testing is of little use
B	avidity testing requires expert advice
C	avidity < 30% indicates infection in the previous 3 months
D	avidity < 30% indicates infection in the previous 6 months
E	avidity < 30% indicates infection in the previous 9 months
F	avidity > 40% indicates infection more than 3 months previously
G	avidity > 40% indicates infection more than 6 months previously
H	avidity > 40% indicates infection more than 9 months previously
I	none of the above

Question 8.        Which, if any, of the following are true in relation to the NSC’s decision on routine

toxoplasmosis screening in pregnancy in 2016?

Option list.

A	screening should be introduced as soon as practicable
B	testing would produce a falsely-high prevalence of Tg in pregnancy
C	the prevalence of Tg is too low for screening to be cost-effective
D	the prevalence of Tg is high enough  for screening to be cost-effective
E	the prevalence of Tg is unknown
F	there is no treatment in pregnancy of proven benefit to mother or baby
G	they would leave the decision until after lunch, but drank too much wine and did not return
H	maybe some of the above, please tick the boxes for me
I	none of the above

Question 9.             Which, if any, of the following are complications of intrauterine Tg infection for the fetus and newborn.

Option list.

A	miscarriage
B	IUGR
C	stillbirth
D	chorioretinitis
E	hepato-splenomegaly
F	holoprosencephaly
G	hydrocephalus
H	intracranial calcification
I	microcephaly
J	neural tube defect

Question 10.    Approximately how common in vertical transmission of Tg in the 1^st. trimester?

Option list.

A	< 10%
B	10-20%
C	25%
D	50%
E	> 50%

Question 11.    Approximately how common in vertical transmission of Tg in the 2^nd. trimester? Use

the option list for question 4.

Option list.

A	< 10%
B	10-20%
C	25%
D	50%
E	> 50%

Question 12.         Approximately how common in vertical transmission of Tg in the 3^rd. trimester? Use the option list for question 4.

Option list.

A	< 10%
B	10-20%
C	25%
D	50%
E	> 50%

Question 13.         Which of the following are true in relation to reducing the risk of vertical transmission of Tg?

Option list.

A	the SYROCOT trial showed strong evidence of the efficacy of spiramycin
B	a Cochrane trial has suggested that pyrimethamine + sulfadiazine give better results than spiromycin
C	there is evidence that metronidazole is the most effective drug
D	there is a lack of clear evidence about effective therapies
E	spiromycin crosses the placenta, so is effective in reducing MTBT and treating the infected fetus
E	this is too esoteric for my poor pummelled brain

Question 14.         Which, if any, of the following are features of the classical triad associated with congenital Tg?

Option list.

A	chorioretinitis
B	deafness
C	hepatosplenomegaly
D	hydrocephalus
E	intracranial calcifications
F	low birthweight
G	jaundice
H	leukopenia

Question 15.    Which of the following are used in the treatment of cTg?

Option list.

A	metronidazole
B	pyrimethamine
C	steroids
D	sulfadiazine
E	none of the above.

 

40.         UKOSS. SBA.

Abbreviations.

NPEU:   National Perinatal Epidemiology Unit.

OU:       Oxford University.

RCPCE: Royal College of Paediatrics and Child Health.

Question 1.   What is the UKOSS?

Option list.

A	UK Obstetrics Social Society
B	UK Obstetric Surveillance System
C	UK Obstetric Students’ Society
D	UK Organisation for Social Support
E	UK Organisation for Superior Sausages
F	UK Over-sized Surveillance System

Question 2.   Which organisations collaborate in UKOSS?

Option list.

A	DOH
B	NHS
C	NPEU
D	OU
E	RCOG
F	RCPCH
G	WHO

Question 3.   What definition is used for ‘rare’ by UKOSS?

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 4.   What are the key mechanisms that make UKOSS’s results valuable?

Option list.

A	active identification of cases
B	all obstetricians in the UK requested to report cases
C	nominated personnel in each UK maternity unit report cases
D	proactive pursuit of clinical data
E	wide dissemination of data

Question 5.   Which, if any, of the following are the main focus of UKOSS studies?

Option list.

A	‘granny’ conditions in the elderly
B	‘near misses’
C	‘orphan’ conditions for which research funding is rarely available
D	rare conditions
E	topics selected annually by consultants at the annual professional development conference

Question 6.        Which, if any, of the following were conclusions in the enquiry into AFE between 2009

& 11?

Option list.

A	cases to be transferred to tertiary centres ASAP
B	11 deaths in the UK
C	estimated incidence of AFE ~ 1 in 50,000
D	perimortem Cs to be done within 5 minutes of collapse and for maternal benefit
E	plasma, platelets and red cells to be used early to avoid dilutional effects
F	protocol for massive obstetric haemorrhage to be used early

Question 7.   How are the results of OKOSS’s studies communicated?

Option list.

A	by post to all subscribers
B	via quarterly newsletters
C	via annual reports
D	via monthly podcasts
E	via peer-reviewed publications
F	via the UKOSS websites
G	via TOG updates