Tutorial. 25 May 2023

 

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12	EMQ. The Term Breech Trial
13	Part 3. Create ‘blurb’. General pre-pregnancy counselling
14	EMQ. Hepatitis C
15	MCQ. The Coombs test
16	EMQ. Mayer-Rokitansky-Küster-Hauser syndrome

 

12.         The Term Breech Trial.

Abbreviations.

Cs:              Caesarean section.

ECV:           external cephalic version.

VB:              vaginal birth.

VBD:           vaginal breech delivery.

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

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.

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?

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?

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?

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?

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?

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.

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

 

 

 

13.         Part 3. Create ‘blurb’. General pre-pregnancy counselling.

 

14.         Hepatitis C.

Hepatitis C & pregnancy. HCV. EMQ. Questions

Abbreviations.

DAAD:           Direct-acting, antiviral drug.

HBV:              Hepatitis B virus.

HCV:              Hepatitis C virus.

HCAb:           Hepatitis C antibody.

ROM:            Rupture of membranes.

Scenario 1.         Which, if any, of the following statements are true?

Option list.

A	Hepatitis kills more people world-wide than HIV
B	Hepatitis kills more people world-wide than TB
C	Hepatitis B kills more people world-wide that Hepatitis C
D	Hepatitis B kills more people world-wide than TB
E	None of the above

Scenario 2.         Which, if any, of the following statements are true in relation to HCV?

Option list.

A	It is a DNA virus
B	It is a RNA virus
C	It is a member of the Flaviviridae family
D	it is a member of the Hepadnaviridae family
E	it is a member of the Herpesviridae family
F	most infections are due to genotypes 1 & 3
G	most infections are due to genotypes 2 & 4

Scenario 3.         What is the approximate prevalence of HCV infection in the UK?

Option list.

A	0.1 per 1,000
B	0.3 per 1,000
C	0.5 per 1,000
D	1 per 1,000
E	3 per 1,000
F	5 per 1,000
G	10 per 1,000
H	13 per 1,000
I	15 per 1,000
J	None of the above

Scenario 4.         What are the key aspects of the WHO’s Global Health Sector Strategy in relation to

HCV infection?

Option list.

A	elimination as a as a major public health threat by 2020
B	elimination as a as a major public health threat by 2030
C	elimination as a as a major public health threat by 2040
D	reduction in incidence by 50% by 2030
E	reduction in incidence by 75% by 2030
F	reduction in incidence by 80% by 2030
G	reduction in mortality by 50% by 2030
H	reduction in mortality by 65% by 2030
I	reduction in mortality by 70% by 2030

Scenario 5.         What is the incubation period of HCV infection?

Option list.

A	6 weeks
B	2 months
C	up to 3 months
D	up to 4 months
E	up to 6 months
F	up to 12 months
G	none of the above

Scenario 6.         What symptoms are most common in acute HCV infection? There is no option list.

Scenario 7.         How is acute HCV infection diagnosed?

Option list.

A	clinically
B	presence of HCV antibody
C	presence of HCV RNA
D	none of the above

Scenario 8.         What proportion of those with acute HCV infection are asymptomatic?

Option list.

A	10%
B	20%
C	50%
D	60%
D	70%
E	> 80%

Scenario 9.         When does continuing infection after initial exposure become defined as chronic

infection?

Option list.

A	after 6 weeks
B	after 2 months
C	after 3 months
D	after 4 months
E	after 6 months
F	after 12 months
G	none of the above

Answer. E. After 6 months.

Scenario 10.      Approximately how many of those with acute HCV infection will go on to chronic

infection?

Option list.

A	10%
B	20%
C	40%
D	50%
E	>50%
F	>70%

Scenario 11.      A woman is found to have HCV antibodies. Which, if any, of the following statements

could be true?

Option list.

A	she could have acute HCV infection
B	she could have chronic infection
C	she could have had HCV infection that has cleared spontaneously
D	she could have had HCV infection that has responded to drug therapy
E	she could have a false +ve test result
F	she could have chronic HBV infection due to cross reaction with HBcAg
G	she is immune to HCV
H	the antibodies could result from HCV vaccine
I	the antibodies could result from yellow fever vaccine
J	none of the above

Scenario 12.      Which, if any, of the following statements reflect current thinking about the

mechanisms of damage in chronic HCV infection?

Option list.

A	hepatic damage is proportional to the duration of HCV infection
B	hepatic damage is a direct result of HCV replication within hepatocytes
C	hepatic damage is proportional to the level of detectable HCV RNA in maternal blood
D	hepatic damage is immune-mediated
E	hepatic damage is due to progressive biliary tract infection, scarring  and stenosis
F	hepatic damage mostly occurs in women who abuse alcohol
G	hepatic damage is worse in women with co-existing HIV infection
H	hepatitis D is end-stage hepatitis C, with cirrhosis and liver failure, ‘D’ originating from the original name: ‘deadly-stage’ HCV disease

Scenario 13.      How common is vertical transmission? There is no option list.

Scenario 14.      Which, if any, of the following statements are true in relation to the hepatitides?.

A	acute hepatitis is notifiable
B	chronic hepatitis is notifiable
C	hepatitis A is notifiable as the main route of spread is faecal contamination of food & water
D	hepatitis D is notifiable as the main source of infection is infected food and water
E	hepatitis E is notifiable as the main source of infection in the UK is raw or undercooked pork
F	none of the above

Scenario 15.      What anti-viral treatment is recommended for pregnancy? There is no option list.

Scenario 16.      Which, if any, of the following are true about Ribavirin?

Option list.

A	it is the least expensive of the new DAADs for HCV
B	it is the least toxic of the new DAADs for HCV
C	it is the most effective of the new DAADs for HCV
D	it is contraindicated in pregnancy because of fears of teratogenicity
E	can cause sperm abnormalities
F.	can persist in humans for up to 6 months
G.	none of the above

Scenario 17.      A woman with chronic HCV wishes to breastfeed. What advice would you give? There is no option list.

Scenario 18.      How is neonatal infection diagnosed? There is no option list.

Scenario 19.      How is neonatal infection treated? There is no option list.

Scenario 20.      Which, if any, of the following conditions is more common in women with HCV infection?

Option list.

A	dermatitis herpetiformis
B	HELLP syndrome
C	obstetric cholestasis
D	postnatal depression
E	thrombocytopenia

Scenario 21.      By how much is the risk of the condition in question 20 increased in women with HCV?

Option list.

A	by a factor of 2
B	by a factor of 5
C	by a factor of 20
D	by a factor of 50
E	none of the above

Scenario 22.      Which, if any, of the following statements is true about HCV and the Nobel Prize?

Option list.

A	the Nobel Prize was awarded to Alter, Houghton & Rice in 2020
B	the Nobel Prize was awarded to Alter, Hogg & Rice in 2020
C	the Nobel Prize was awarded to Alter, Houghton & Rees in 2020
D	the Nobel Prize was awarded to Change, Houghton & Rice in 2020
E	the Nobel Prize was awarded to Change, Hogg & Rice in 2020
F	the Nobel Prize was awarded to Change, Hogg & Barleycorn in 2020
G	the Nobel Prize has not been awarded for work on HCV

 

15.         The Coombs test. MCQ.

This is an MCQ, so the answers are just ‘true’ or ‘false’.

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.

 

16.         Mayer-Rokitansky-Küster-Hauser syndrome.

Note. Some of the questions are not true EMQs as there may be more than one correct answer – this is me being lazy and saving typing.

Mayer–Rokitansky–K

¨

uster–Hauser

syndrome: diagnosis and management

With regard to the MRKH syndrome,

61. there is failure of development of the

mesonephric ducts. T F

62. the phenotype and genotype are female. T F

63. studies have established a link between the

syndrome and the use of diethylstilbestrol in

pregnancy. T F

With regard to the anatomical abnormalities seen in

MRKH syndrome,

64. symmetrical uterovaginal aplasia is found in

type I disorders. T F

65. renal abnormalities are seen in more than

half of cases. T F

66. skeletal abnormalities are reported in up to

one-fifth of cases. T F

67. up to one-quarter of women have a

malformed ear or auditory canal. T F

68. the close proximity of the m

¨

ullerian and

wolffian duct derivatives to the metanephric

duct in the developing embryo explains the

higher association of malformations of the

kidneys with this condition. T F

69. vaginal agenesis is caused by failure of the

caudal part of the m

¨

ullerian duct system to

develop. T F

Regarding the diagnosis of MRKH syndrome,

70. magnetic resonance imaging is the gold

standard tool. T F

71. two-dimensional ultrasound scanning is not

useful for associated renal tract

abnormalities. T F

72. complete androgen insensitivity syndrome is

an important differential diagnosis. T F

73. the presence of cyclical abdominal pain will

rule out the diagnosis, as it indicates the

presence of functioning endometrium. T F

With regard to the creation of a neovagina,

74. it is recommended that treatment is initiated

as soon as the diagnosis is made. T F

75. psychological support to women undergoing

this procedure is of the utmost importance. T F

76. vaginal dilators are acceptable as an option

for first-line therapy. T F

77. Ingram’s modified Frank’s technique involves

the use of vaginal dilators. T F

With regard to the surgical creation of a neovagina,

78. in the Davydov procedure the neovagina is

lined with peritoneum. T F

With regard to fertility in women with the MRKH

syndrome,

79. transvaginal egg retrieval is recognised to be

difficult during in vitro fertilisation. T F

80. the condition has been shown to be

transmissible to the offspring. T F

Abbreviations.

AIS:          androgen insensitivity syndrome

AMH:       anti- Müllerian hormone

MRKH:     Mayer-Rokitansky-Küster-Hauser syndrome

MURCS:  Müllerian duct aplasia, renal dysplasia and cervical somite anomaly syndrome.

Question 1.        What are the main features of MRKH? There is no option list to make life harder.

Question 2.        Which, if any, are the main secondary features associated with MRKH?

Option list.

A	anosmia
B	attention-deficit-hyperactivity syndrome
C	auditory anomalies
D	neural tube defects
E	renal anomalies
F	skeletal anomalies

Question 3.        How does MRKH syndrome usually present?

Option list.

A	cyclical pain due to haematometra
B	delayed puberty
C	precocious puberty
D	premature menopause
E	primary amenorrhoea
F	recurrent otitis media
G	recurrent urinary tract infection
H	secondary amenorrhoea

Question 4.        Which of the following chromosome patterns are typical of MRKH?

Option list.

A	45XO
B	45YO
C	46XX
D	46XY
E	47XXX
F	47XXY

Question 5.        What is the approximate incidence of MRKH in newborn girls?

Option list.

A	~ 1 in 1,000
B	~ 1 in 2,000
C	~ 1 in 4,000
D	~ 1 in 6.000
E	~ 1 in 8,000
F	~ 1 in 10,000
G	~ 1 in 100,000
H	the figure is unknown
I	it does not occur

Question 6.        What is the approximate incidence of MRKH in newborn boys?

Option list.

A	~ 1 in 1,000
B	~ 1 in 2,000
C	~ 1 in 4,000
D	~ 1 in 6.000
E	~ 1 in 8,000
F	~ 1 in 10,000
G	~ 1 in 100,000
H	the figure is unknown
I	it does not occur

Question 7.             Which of the following statements are correct in relation to urinary tract anomalies associated with MRKH?

Option list.

A	absent bladder
B	absent kidney
C	ectopic ureter
D	horseface kidney
E	hypospadias
F	urinary tract anomalies are not part of the syndrome

Question 8.             Which of the following statements are correct in relation to skeletal anomalies associated with MRKH?

Option list.

A	absent thumb
B	absent big toe
C	developmental dysplasia of the hip
D	Klippel-Feil anomaly
E	ulnar hypoplasia
F	vertebral fusion
G	skeletal anomalies are not part of the syndrome

Question 9.             Which of the following statements are correct in relation to auditory anomalies associated with MRKH?

Option list.

A	absent ear
B	absent stapes
C	acoustic neuroma
D	conductive deafness
E	inductive deafness
F	stapedial ankylosis
G	auditory anomalies are not part of the syndrome

Question 10.    What is the recommended first-line management for creation of a neovagina.

Option list.

A	digital dilatation
B	marriage to a virile husband
C	vaginal balloons
D	vaginal dilators
E	vaginoplasty
F	there is no recommended 1st. line management

Question 11.     What are the key features of Davydov vaginoplasty?

Option list.

A	horseshoe perineal incision with labial flaps used to create a pouch
B	creation of space between bladder and rectum and lining it with amnion
C	creation of space between bladder and rectum and lining it with skin graft
D	creation of space between bladder and rectum and lining it with sigmoid colon
E	creation of space between bladder and rectum and lining it with peritoneum
F	traction via threads running to the abdomen from a vaginal bead

Question 12.    What are the key features of McIndoe vaginoplasty?

Option list.

A	horseshoe perineal incision with labial flaps used to create a pouch
B	creation of space between bladder and rectum and lining it with amnion
C	creation of space between bladder and rectum and lining it with skin graft
D	creation of space between bladder and rectum and lining it with sigmoid colon
E	creation of space between bladder and rectum and lining it with peritoneum
F	traction via threads running to the abdomen from a vaginal bead

Question 13.    What are the key features of Vecchietti vaginoplasty?

Option list.

A	horseshoe perineal incision with labial flaps used to create a pouch
B	creation of space between bladder and rectum and lining it with amnion
C	creation of space between bladder and rectum and lining it with skin graft
D	creation of space between bladder and rectum and lining it with sigmoid colon
E	creation of space between bladder and rectum and lining it with peritoneum
F	traction via threads running to the abdomen from a vaginal bead

Question 14.    What are the key features of Williams vaginoplasty?

Option list.

A	horseshoe perineal incision with labial flaps used to create a pouch
B	creation of space between bladder and rectum and lining it with amnion
C	creation of space between bladder and rectum and lining it with skin graft
D	creation of space between bladder and rectum and lining it with sigmoid colon
E	creation of space between bladder and rectum and lining it with peritoneum
F	traction via threads running to the abdomen from a vaginal bead

TOG CPD questions.

With regard to the MRKH syndrome.

1.     there is failure of development of the mesonephric ducts.                                     True / False

2.     the phenotype and genotype are female.                                                                   True / False

3.     studies have established a link between the syndrome and the use of diethylstilboestrol in pregnancy.                                                                                                                              True / False

With regard to the anatomical abnormalities seen in MRKH syndrome.

4.     symmetrical uterovaginal aplasia is found in type I disorders.                                True / False

5.     renal abnormalities are seen in more than half of cases.                                         True / False

6.     skeletal abnormalities are reported in up to one-fifth of cases.                              True / False

7.     up to one-quarter of women have a malformed ear or auditory canal.                    True / False

8.     the close proximity of the Müllerian and Wolffian duct derivatives to the duct in the developing embryo explains the higher association of malformations of the kidneys with this condition.

True / False

9.     vaginal agenesis is caused by failure of the caudal part of the Müllerian duct system to develop.

True / False

Regarding the diagnosis of MRKH syndrome,

10.   magnetic resonance imaging is the gold standard tool.                                            True / False

11.   two-dimensional ultrasound scanning is not useful for associated renal tract abnormalities.

True / False

12.   complete androgen insensitivity syndrome is an important differential diagnosis.  True / False

13.   the presence of cyclical abdominal pain will rule out the diagnosis, as it indicates the presence of functioning endometrium.                                                                                          True / False

With regard to the creation of a neovagina,

14.   it is recommended that treatment is initiated as soon as the diagnosis is made.     True / False

15.   psychological support to women undergoing this procedure is of the utmost importance.

True / False

16.   vaginal dilators are acceptable as an option for first-line therapy.                         True / False

17.   Ingram’s modified Frank’s technique involves the use of vaginal dilators.                    True / False

With regard to the surgical creation of a neovagina,

18.   in the Davydov procedure the neovagina is lined with peritoneum.                      True / False

With regard to fertility in women with the MRKH syndrome,

19.   transvaginal egg retrieval is recognised to be difficult during in vitro fertilisation.             True / False

20.   the condition has been shown to be transmissible to the offspring.                      True / False