15 June 2023

 

15 June 2023.

 

Teresa Kelly is a consultant obstetrician at St. Mary’s hospital where she runs the service for COVID in pregnancy. She has a relative with a recent illness which has made planning dates for her to talk difficult. She hopes to be available on the 15^th. If not, we’ll try to find an alternative.

She is an expert on COVID and an excellent speaker with lots of advice for the exam and practice, so a ‘not-to-be-missed’ event. She is happy to answer questions, so it is best to attend on line, but the talk will be available to download from Dropbox – I know many of you can’t manage 6pm.

I have put enough stuff on the agenda for us to have a complete programme if Teresa can’t make it.

 

35	Tutorial. Teresa Kelly. COVID.
36	EMQ. Headache
37	SBA.   Lynch syndrome
38	Viva. von Willebrand disease
39	EMQ. Edward syndrome
40	SBA. Meigs syndrome
41	SBA. Appendicitis in pregnancy

 

35.   Tutorial. COVID. Teresa Kelly.

Teresa is a consultant obstetrician at St. Mary’s hospital where she runs the service for COVID in pregnancy. She has a relative with a recent illness which has made planning dates for her to talk difficult. She hopes to be available on the 15^th. If not, we’ll try to find an alternative date, though that might have to be on an evening that is not a Monday or Thursday.

She is an expert on COVID and an excellent speaker with lots of advice for the exam and real-life practice, so a ‘not-to-be-missed’ event. She is happy to answer questions making it best to attend on line, but the talk will be available to download from Dropbox – I know many of you can’t manage 6pm. I have put enough stuff on the agenda for us to have a complete programme if Teresa can’t make it.

 

36.   Headache.

Option list.

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 405-year-old para 3 is admitted at 38 weeks by ambulance with severe headache of sudden onset. She d6escribes 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.

Scenario 14. This is not an EMQ. It relates to the incidence of various conditions in women who have migraine. Choose the appropriate arrow for each.

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. Lynch syndrome       .

Abbreviations

CRC:              colorectal cancer.

EC:                 endometrial cancer.

IBD:               inflammatory bowel disease: Crohn’s & ulcerative colitis.

IDDM:           insulin-dependent diabetes mellitus.

Ls:                  Lynch syndrome.

MLH:             mutL-homolog family of DNA, mismatch repair genes.

MMR:           mismatch repair.

MSH:             mutS homolog family of DNA, mismatch repair genes.

Question 1.        What is Lynch syndrome?

Option List

A	auto-immune condition leading to reduced factor X levels in blood
B	hereditary condition which increases the risk of many cancers, particularly breast
C	hereditary condition which increases the risk of many cancers, particularly breast & colorectal
D	hereditary condition which increases the risk of many cancers, particularly colorectal & endometrial
E	none of the above

Question 2.        How is Lynch syndrome inherited?

Option List

A	it is an autosomal dominant condition
B	it is an autosomal recessive condition
C	it is an X-linked dominant condition
D	it is an X-linked recessive condition
E	none of the above

Question 3.        Which, if any, of the following genes can cause Lynch syndrome?

Option List

A	MLH1 + MLH2 + MOH1
B	MLH1 + MLH2 + MSH1
C	MLH1 + MLH2 + MSH6
D	MLH1 + MSH2 + MSH6
E	None of the above

Question 4.        Mutations of which 2 of the following genes cause most cases of Lynch syndrome?

Option List

A	MLH1 + MLH2
B	MLH1 + MSH1
C	MLH1 + MSH2
D	MLH2 + MSH1
E	MLH2 + MSH2

Question 5.        What is the approximate prevalence of Ls in the UK population?

Option List

A	1 in 50
B	1 in 100
C	1 in 1,000
D	3 in 1,000
E	none of the above

Question 6.        Approximately what % of individuals with Ls have had the diagnosis established?

Option List

A	< 5%
B	5 -10%
C	10-20%
D	20-30%
E	>30%

Question 7.        Which, if any, of the following conditions are associated with an ↑ risk of Ls?

Option List

A	acromegaly + Addison’s disease + coeliac disease + IBD + IDDM
B	acromegaly + disease + anosmia + coeliac disease + IBD
C	acromegaly + IBD + IDDM
D	acromegaly + IBD
E	Addison’s disease + anosmia + coeliac disease + IBD + IDDM
F	acromegaly + Addison’s disease + anosmia + coeliac disease + IBD + IDDM
G	none of the above

Question 8.        Which 2 cancers are most likely in women with Lynch syndrome?

Option List

A	breast + bowel
B	breast + pancreas
C	breast + endometrium
D	bowel + cervix
E	bowel + endometrium
F	bowel + ovary
G	bowel + pancreas
H	endometrium + ovary

Question 9.        What does NICE recommend about screening for Lynch syndrome for the population

with no personal history of colorectal cancer?

Option List

A	offer screening to those aged < 50 years with  ≥ 1 affected 1st.O relative
B	offer screening to those aged < 60 years with ≥ 1 affected 1st.O relative
C	offer screening to those with ≥ 1 affected 1st.O relative aged < 50 years at diagnosis
D	offer screening to those with ≥ 1 affected 1st.O relative aged < 60 years at diagnosis
E	none of the above

Question 10.    What does NICE recommend in relation to screening for Lynch syndrome in those with

a new diagnosis of colorectal cancer?

Option List

A	offer screening to everyone, regardless of age and family history
B	offer screening to those aged < 50 years at diagnosis
C	offer screening to those aged < 60 years at diagnosis
D	offer screening to those aged < 50 years at diagnosis with + ≥ 1 affected 1st.O relative
E	offer screening to those aged < 60 years at diagnosis with + ≥ 1 affected 1st.O relative

Question 11.    What does NICE recommend about screening for Lynch syndrome for the population

with no personal history of thyroid cancer?

Option List

A	offer screening to those aged < 50 years with  ≥ 1 affected 1st.O relative
B	offer screening to those aged < 60 years with ≥ 1 affected 1st.O relative
C	offer screening to those with ≥ 1 affected 1st.O relative aged < 50 years at diagnosis
D	offer screening to those with ≥ 1 affected 1st.O relative aged < 60 years at diagnosis
E	none of the above

Question 12.         What does NICE recommend in relation to screening for Lynch syndrome in those

with a new diagnosis of thyroid cancer?

Option List

A	offer screening to everyone, regardless of age and family history
B	offer screening to those aged < 50 years at diagnosis
C	offer screening to those aged < 60 years at diagnosis
D	offer screening to those aged < 50 years at diagnosis with + ≥ 1 affected 1st.O relative
E	none of the above

Question 13.    What does NICE recommend about screening for Lynch syndrome for the population

 with no personal history of endometrial cancer?

Option List

A	offer screening to those aged < 50 years with  ≥ 1 affected 1st.O relative
B	offer screening to those aged < 60 years with ≥ 1 affected 1st.O relative
C	offer screening to those with ≥ 1 affected 1st.O relative aged < 50 years at diagnosis
D	offer screening to those with ≥ 1 affected 1st.O relative aged < 60 years at diagnosis
E	none of the above

Question 14.    What does NICE recommend in relation to screening for Lynch syndrome in those with

a new diagnosis of endometrial cancer?

Option List

A	offer screening to those aged < 50 years with  ≥ 1 affected 1st.O relative
B	offer screening to those aged < 60 years with ≥ 1 affected 1st.O relative
C	offer screening to those with ≥ 1 affected 1st.O relative aged < 50 years at diagnosis
D	offer screening to those with ≥ 1 affected 1st.O relative aged < 60 years at diagnosis
E	none of the above

Question 15.    What does NICE recommend about screening for Lynch syndrome for the population

with no personal history of colorectal cancer?

Option List

A	offer screening to those aged < 50 years with  ≥ 1 affected 1st.O relative
B	offer screening to those aged < 60 years with ≥ 1 affected 1st.O relative
C	offer screening to those with ≥ 1 affected 1st.O relative aged < 50 years at diagnosis
D	offer screening to those with ≥ 1 affected 1st.O relative aged < 60 years at diagnosis
E	none of the above

Question 16.    What does NICE recommend in relation to screening for Lynch syndrome in those with

a new diagnosis of colorectal cancer?

Option List

A	offer screening to everyone, regardless of age and family history
B	offer screening to those aged < 50 years at diagnosis
C	offer screening to those aged < 60 years at diagnosis
D	offer screening to those aged < 50 years at diagnosis with + ≥ 1 affected 1st.O relative
E	offer screening to those aged < 60 years at diagnosis with + ≥ 1 affected 1st.O relative

Question 17.    What relationship, if any, exists between Ls and acromegaly?

Option List

A	the risk of Ls is ↓ in those with acromegaly compared with the general population
B	the risk of Ls is ↑ in those with acromegaly compared with the general population
C	the risk of Ls is unchanged in those with acromegaly compared with the general population
D	the risk of Ls in unknown in those with acromegaly
E	none of the above

Question 18.    What is the effect of aspirin consumption on the risk of EC and CRC?

Option List

A	aspirin reduces the risk of EC and CRC
B	aspirin reduces the risk of EC but not CRC
C	aspirin reduces the risk of CRC but not EC
D	aspirin does not reduce the risk of EC or CRC
E	aspirin reduces the risk of EC and CRC, but the risks outweigh the benefits

Question 19.    A healthy woman of 35 years is diagnosed with Ls? What are the key elements of the

National Screening Programme for people with Ls?

There is no option list – just write down everything you know.

Question 20.    Which, if any, of the following were recommendations made by Monahan et al, the 30

experts who wrote to the BMJ in 2017.

Option List

A	creation of a national register of people with Ls
B	creation of a post of Consultant in Ls for each NHS Trust
C	creation of a post of Clinical Champion for Ls in each NHS Region.
D	creation of a post of Clinical Champion for Ls in the DOH.
E	none of the above

With regard to Lynch syndrome,

1.     loss of mismatch repair protein expression on immunohistochemistry of cancer is diagnostic.

True/False

2.     most carriers of the mutation associated with the syndrome know they have the condition.

True/False

3.     the first cancers associated with the syndrome are predominantly endometrial or ovarian cancers.                                                                                                                               True/False

4.     when cancers occur, they have in them an unusually high immune infiltrate.    True/False

With regard to testing for Lynch syndrome,

5.     consent must be sought before definitive germline testing for Lynch syndrome by a trained professional.                                                                                                                       True/False

6.     immunohistochemical staining of tumours for the mismatch repair proteins or microsatellite instability analysis are recognised ways of screening cancers for characteristics suggestive of the syndrome.                                                                                                                     True/False

7.     the National Institute for Health and Care Excellence endorses universal screening of colorectal cancer patients for Lynch syndrome.                                                                               True/False

8.     most gynaecological cancers found to have aberrant mismatch repair immunohistochemical staining will be in those with the syndrome.                                                  True/False

9.     the addition of MLH1 promotor hypermethylation testing in a Lynch syndrome diagnostic pathway improves specificity.                                                                               True/False

Regarding gynaecological surveillance in women with Lynch syndrome,

10.   there is strong evidence to recommend its use.                                                         True/False

11.   this should be offered to women around 25 years of age.                                       True/False

12.   counselling should include education on red flag symptoms of cancer and risk-reducing surgery.

True/False

With regard to risk-reducing strategies for women with Lynch syndrome,

13.   hysterectomy is strongly recommended for all those with the syndrome.               True/False

14.   the timing of risk-reducing surgery depends on the syndrome gene.                     True/False

15.   where possible, a laparoscopic approach is recommended.                                    True/False

16.   aspirin is not recommended as a means of reducing their overall cancer risk.              True/False

Regarding Lynch syndrome-associated gynaecological cancers,

17.   endometrial types that arise as a result of the syndrome have a poorer prognosis than sporadic types.                                                                                                                                 True/False

18.   checkpoint inhibition of the PD-1/PD-L1 pathway has been shown to be very effective in mismatch repair-deficient cancers.                                                                                       True/False

19.   vaccination against these cancers is currently the focus of research.                     True/False

20.   the Manchester International Consensus guideline is a useful reference for gynaecologists managing women with these cancers.                                                                True/False

 

38.   von Willebrand disease.

Candidate's Instructions.

This is a viva station. The examiner will ask you 21 questions.

 

39.   Edward syndrome.

Abbreviations.

ES:            Edward syndrome. T₁₈.

DS:           Down syndrome.    T₂₁.

MSAFP:   maternal serum α-feto-protein.

PAPP-A:   pregnancy-associated plasma protein-A.

PS:            Patau syndrome.    T₁₃.

Some of the questions are not true EMQs as there may be > 1 correct answer. The use of ‘is’ or ‘are’ usually indicates which are or are not true EMQs.                

Question 1.             Which, if any, of the following are features of ED.

Option list.

A	abnormal head shape
B	atrial septal defect
C	camptodactyly
D	cleft lip
E	clenched fingers
F	corpus callosum hypoplasia
G	cryptorchidism
H	exomphalos
I	gastroschisis
J	IUGR
K	large ears
L	low birthweight
M	macroorchidism
N	micrognathia
O	myelomeningocoele
P	omphalocoele
Q	overlapping fingers
R	rocker bottom
S	none of the above

Question 2.             Which of the following statements is true?

Option list.

A	ES is the most common autosomal trisomy
B	ES is the 2nd. most common autosomal trisomy
C	ES is the 3rd. most common autosomal trisomy
D	ES is the 4th. most common autosomal trisomy
E	none of the above

Question 3.             What is the approximate incidence of ED in neonates?

Option list.

A	1 in 1,000
B	1 in 2,000
C	1 in 5,000
D	1 in 10,000
E	1 in 100,000
F	none of the above

Question 4.             Which, if any, of the following are true in relation to ES and screening tests in the 1^ST. and 2^nd. trimesters?

Option list.

A	β-hCG is increased
B	β-hCG is normal
C	β-hCG is decreased
D	PAPP-A is increased
E	PAPP-A is normal
F	PAPP-A is decreased
G	inhibin A is increased
H	inhibin A is normal
I	inhibin A is decreased
J	MSAFP is increased
K	MSAFP is normal
L	MSAFP is decreased
M	nuchal translucency is increased
N	nuchal translucency is normal
O	nuchal translucency is decreased
P	unconjugated oestriol  is increased
Q	unconjugated oestriol  is normal
R	unconjugated oestriol  is decreased

Question 5.             Which, if any, of the following are true in relation to ES and choroid plexus cysts?

Option list.

A	CPC are not more common in ES
B	CPCs are the most frequent reason for suspecting ES
C	CPCs are seen in ≥ 50% of fetuses with ES
D	CPC + another anomaly give a high risk of ES
E	CPCs persist longer in ES
F	none of the above

Question 6.             What % of neonates with T18 survive to 1 year of age.

Option list.

A	< 1 %
B	1-5%
C	6-10%
D	10-15%
E	> 15%

 

40.   Meigs’ syndrome.

Scenario1.    Which, if any, of the following are features of Meigs syndrome?

Option List

A	ascites
B	bilateral ovarian tumours
C	Gorlin syndrome
D	most common in women < 25 years
E	ovarian fibroma
F	ovarian metastatic malignancy
G	primary gastro-intestinal tumour
H	precocious puberty
I	primary amenorrhoea
J	postmenopausal bleeding
K	resolution of symptoms after oophorectomy
L	right-sided hydrothorax
M	signet ring cells

 

41.   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

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.

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.