|
51 |
Role-play. Previous stillbirth. |
|
52 |
EMQ. Cytomegalovirus and Pregnancy. CMV |
|
53 |
EMQ. Montgomery & consent |
51. Role-play. Previous stillbirth.
Candidate's Instructions.
This is a roleplay station. You are an SpR in the booking
clinic. You are about to see a woman who is at 10 weeks’ gestation in her
second pregnancy. Her first baby was stillborn. She has had all the routine
booking, including investigations, dealt with by the midwife who has asked you
to see her to advise about her first pregnancy and its implications for the
management of this pregnancy.
Take an appropriate history, advise about the necessary
investigations and how the history of stillbirth will influence the management
of the pregnancy.
52. Cytomegalovirus
and Pregnancy. CMV.
Abbreviations.
AI: avidity
index.
CMV: cytomegalovirus.
CNS: central
nervous system.
HIG: hyperimmunoglobulin.
Scenario 1.
What does the term
“cytomegalovirus” mean?
Option list.
|
A |
it is an unusually large virus |
|
B |
it is the largest known virus |
|
C |
the viral cytoplasm is increased in volume |
|
D |
infected cells are enlarged and have enlarged nuclei |
|
E |
none of the above |
Scenario 2.
Which of the following
terms is used in relation to CMV infected cells?
Option list.
|
A |
almond-eyed |
|
B |
apple of my eye |
|
C |
cross-eyed |
|
D |
doe-eyed |
|
E |
owl-eyed |
Scenario 3.
Which family of
viruses does CMV belong to?
Option list.
|
A |
Adenoviridae |
|
B |
Arachnoviridae |
|
C |
Enteroviridae |
|
D |
Herpesviridae |
|
E |
Poxviridae |
Scenario 4.
What kind of virus
is CMV?
Option list.
|
A |
bacteriophage |
|
B |
DNA virus |
|
C |
RNA virus |
|
D |
none of the above |
Scenario 5.
What is the structure
of the herpes virus?
Option list.
|
A |
double-stranded DNA core, surrounded by three layers:
capsid, tegument and envelope |
|
B |
single-stranded DNA core, surrounded by two layers:
capsid and envelope |
|
C |
double-stranded RNA core, surrounded by three layers:
capsid, tegument and envelope |
|
D |
single-stranded RNA core, surrounded by two layers: capsid
and envelope |
|
E |
none of the above |
Scenario 6.
How many herpes
viruses have been described?
Option list.
|
A |
>1,000 |
|
B |
> 500 |
|
C |
> 250 |
|
D |
> 100 |
|
E |
none of the above. |
Scenario 7.
How many herpes viruses
are of relevance to human infection?
Option list.
|
A |
8 |
|
B |
10 |
|
C |
12 |
|
D |
14 |
|
E |
20 |
Scenario 8.
Write the list of
herpes viruses which affect humans and the conditions they cause?
Option list. There is
none. You have to write your own list.
Scenario 9.
Where does CMV rank
in the list of the most common causes of congenital viral
infection?
Option list.
|
A |
1 |
|
B |
2 |
|
C |
3 |
|
D |
4 |
|
E |
5 |
Scenario 10.
Which of the following
statements is the most accurate in relation to CMV?
Option list.
|
A |
CMV can lie dormant after 1ry. infection, usually in bone
marrow |
|
B |
CMV can lie dormant after 1ry. infection, usually in dorsal
root ganglia |
|
C |
CMV can lie dormant after 1ry. infection, usually in the
lungs |
|
D |
CMV can lie dormant after 1ry. infection, usually in the
salivary glands |
|
E |
CMV does not lie dormant after 1ry. infection |
Scenario 11.
Which, if any, of
the following statements is true of CMV & pregnancy in the UK?
Option list.
|
A |
approximately 10-20% of women are immune before their 1st.
pregnancy |
|
B |
approximately 20-30% of women are immune before their 1st.
pregnancy |
|
C |
approximately 30-50% of women are immune before their 1st.
pregnancy |
|
D |
approximately 40-60% of women are immune before their 1st.
pregnancy |
|
E |
none of the above |
Scenario 12.
Which of the following
statements is true in relation to vertical transmission?
Option list.
|
A |
it is mainly transplacental |
|
B |
it is mainly due to feto-maternal haemorrhage |
|
C |
it mainly occurs during labour and delivery |
|
D |
it mainly occurs during lactation |
|
E |
none of the above |
Scenario 13.
What is the approximate
incidence of 1ry. CMV infection in pregnancy?
Option list.
|
A |
< 1% |
|
B |
< 5% |
|
C |
< 7.5% |
|
D |
< 10% |
|
E |
≥ 10% |
Scenario 14.
What is the biggest
source of CMV infection for women of reproductive age?
Option list.
|
A |
contaminated food or water |
|
B |
blood transfusion |
|
C |
infected sexual partner |
|
D |
infected small children |
|
E |
undercooked meat, particularly pork |
Scenario 15.
What proportion of
1ry. maternal CMV infection in pregnancy is asymptomatic?
Option list.
|
A |
up to 10% |
|
B |
11 – 29% |
|
C |
30 – 49% |
|
D |
50 – 79% |
|
E |
80 – 89% |
|
F |
≥ 90% |
Scenario 16.
What is the approximate
prevalence of CMV infection in UK neonates?
Option list.
|
A |
0.10- 0.25% |
|
B |
0.10- 0.50% |
|
C |
0.20- 0.50% |
|
D |
0.20- 1.00% |
|
E |
0.20- 2.25% |
Scenario 17.
Where does CMV rank
in the non-genetic causes of SNHL in children?
Option list.
|
A |
1 |
|
B |
2 |
|
C |
3 |
|
D |
4 |
|
E |
none of the above |
Scenario 18.
When does vertical
transmission carry the greatest risk of inflicting neurological
damage on the fetus?
Option list.
|
A |
with 1ry infection during the 1st. trimester |
|
B |
with 2ry infection during the 1st. trimester |
|
C |
with 1ry infection during the 2nd. trimester |
|
D |
with 2ry infection during the 2nd. trimester |
|
E |
with 1ry infection during the 3rd. trimester |
|
F |
with 2ry infection during the 3rd. trimester |
|
G |
with 1ry infection during labour / delivery |
|
H |
with 2ry infection during labour / delivery |
|
I |
none of the above |
Scenario 19.
What is the risk
of vertical transmission after CMV infection in the immediate
preconception period?
Option list.
|
A |
< 1% |
|
B |
1-5% |
|
C |
6-10% |
|
D |
11-15% |
|
E |
16-20% |
|
F |
21-30% |
Scenario 20.
A fetus is
infected with CMV at the time of highest risk for neurological damage. What
is the approximate upper limit
for the risk that the child will have neurological damage?
Option list.
|
A |
up to 1% |
|
B |
up to 5% |
|
C |
up to 7.5% |
|
D |
up to 10% |
|
E |
up to 12.5% |
|
F |
up to 15% |
|
G |
up to 20% |
|
H |
none of the above |
Scenario
21. Approximately what % of cerebral palsy is thought attributable
to fetal CMV?
Option list.
|
A |
1% |
|
B |
5% |
|
C |
7.5% |
|
D |
10% |
|
E |
12.5% |
|
F |
15% |
|
G |
20% |
|
H |
25% |
Scenario 22.
Approximately what
% of SNHL is thought attributable to fetal CMV infection?
Option list.
|
A |
1% |
|
B |
5% |
|
C |
7.5% |
|
D |
10% |
|
E |
12.5% |
|
F |
15% |
|
G |
20% |
|
H |
25% |
Scenario 23.
Which, if any, of
the following statements is true of CMV?
Option list.
|
A |
1ry. infection is followed by life-long latent infection |
|
B |
1ry. infection is followed by life-long latent infection
in a minority of cases |
|
C |
life-long latent infection is characteristic of CMV but
not other herpes viruses |
|
D |
life-long latent infection only occurs after 2ry.
infection |
|
E |
none of the above. |
Scenario 24.
How is 1ry.
maternal CMV infection best diagnosed?
Option list.
|
A |
by the regional laboratory |
|
B |
IgM to IgG conversion |
|
C |
presence of IgM with low avidity IgG |
|
D |
religious conversion |
|
E |
sero-conversion from IgG -ve to IgG +ve |
Scenario 25.
Which, if any, of the
following is true in relation to ‘avidity’ in CMV infection?
Option list.
|
A |
avidity declines directly with the interval from 1ry
infection to the test |
|
B |
avidity is an indirect measure of viral load |
|
C |
avidity measures the determination of the obstetrician
to make a diagnosis |
|
D |
avidity measures the enthusiasm of the laboratory for
maximising the cost of testing |
|
E |
avidity measures the strength of binding of CMV antibody
to the virus |
Scenario 26.
Which, if any, of
the following is true in relation to the CMV ‘avidity index’?
Option list.
|
A |
the AI is the ratio of free: albumin-bound CMV IgG in
maternal serum |
|
B |
the AI is the IgG antibody titre in maternal serum |
|
C |
the AI is the percentage of IgG that is bound to the
antigen |
|
D |
the AI is the amount of IgG bound to the antigen
expressed as micrograms / gram |
|
E |
none of the above |
Scenario 27.
Which, if any, of
the following is true in relation to the CMV ‘avidity index’?
Option list.
|
A |
an AI < 30 is indicative of old infection |
|
B |
an AI < 30 is indicative of recent 1ry infection |
|
C |
an AI < 30 suggests a faulty assay |
|
D |
the AI assay used in the NHS is standard across all laboratories |
|
E |
none of the above |
Scenario 28.
Which, if any, of the following
statements is true in relation to identifying women at greatest risk of having
a baby with severe congenital infection?
Option list.
|
A |
a low AI < 18 weeks indicates high risk |
|
B |
a high AI < 18 weeks indicates high risk |
|
C |
a high IgM titre indicates low risk |
|
D |
a high IgG titre indicates high risk |
|
E |
none of the above |
Scenario 29.
What is UK policy
in relation to routine screening for CMV in pregnancy?
Option list.
|
A |
routine screening was introduced in 2018 |
|
B |
routine screening is not advocated because of cost |
|
C |
routine screening is not advocated because of the lack
of an accurate test |
|
D |
routine screening is not advocated because of cross-reaction
with EBV |
|
E |
none of the above |
Scenario 30.
What is UK policy
in relation to routine screening of the neonate for CMV?
Option list.
|
A |
routine screening was introduced in 2015 |
|
B |
routine screening is not advocated because of cost |
|
C |
routine screening is not advocated because of the lack
of an accurate test |
|
D |
routine screening is not advocated because of cross-reaction
with EBV |
|
E |
none of the above |
Scenario
31. Pick the true statements from the list below.
Option list.
|
A |
avidity testing
is not done on CMV IgM antibodies |
|
B |
CMV IgG is a
maverick and does not play by the usual rules |
|
C |
CMV IgM is a maverick
and does not play by the usual rules |
|
D |
CMV IgG persists
for many years |
|
E |
CMV IgM persists
for 1 year or more |
|
F |
none of the above |
Scenario 32.
A woman has been
shown to have had CMV infection in pregnancy. It is decided to
check for evidence of fetal
infection. What does SIP56 say is the mainstay of diagnosing fetal CMV infection.?
Option list.
|
A |
amniocentesis and PCR for evidence of CMV |
|
B |
amniocentesis and electron microscopy for evidence of
CMV |
|
C |
amniocentesis and light microscopy for evidence of CMV |
|
D |
amniocentesis and viral culture |
|
E |
MRI |
|
F |
ultrasound – abdominal |
|
G |
ultrasound - transvaginal |
Scenario 33.
A woman has been shown
to have had CMV infection in pregnancy. Which, if any of
the following statements best
describe the role of MRI scanning in assessing the fetus? This is not a true EMQ
as more than one statement may be true.
Option list.
|
A |
it should be offered in conjunction with ultrasound |
|
B |
it should be offered if ultrasound examination suggests
fetal infection |
|
C |
it should be offered if ultrasound examination does not
suggest fetal infection |
|
D |
it should be offered if there is sufficient funding to
pay for it |
|
E |
the role of MRI scanning is not yet clear |
|
F |
none of the above |
Scenario 34.
A pregnant woman
is HIV+ve? Which of the following statements is true?
Option list.
|
A |
the risk of vertical transmission in pregnancy is ↑ |
|
B |
the risk of vertical transmission in pregnancy is ↓ |
|
C |
the risk of vertical transmission in pregnancy is the
same as in HIV-ve women |
Scenario 35.
A pregnant woman
is HIV+ve? Which of the following statements is true?
Option list.
|
A |
her neonate is at ↑
risk of acquiring CMV perinatally |
|
B |
her neonate is at ↓
risk of acquiring CMV perinatally |
|
C |
her neonate is at normal risk of acquiring CMV
perinatally |
|
D |
none of the above |
Scenario 36.
A pregnant woman
is HIV+ve? Her neonate is +ve for both CMV and HIV. Which of the
following statements is true?
Option list.
|
A |
the child has a ↓
risk of HIV progression and ↓
risk of CNS damage from CMV |
|
B |
the child has a ↓
risk of HIV progression and ↑
risk of CNS damage from CMV |
|
C |
the child has a ↓
risk of HIV progression and normal risk of CNS damage from CMV |
|
D |
the child has an ↑
risk of HIV progression and ↓
risk CNS damage from CMV |
|
E |
the child has an ↑
risk of HIV progression and ↑
risk CNS damage from CMV |
|
F |
the child has an ↑
risk of HIV progression and normal risk of CNS damage from CMV |
|
G |
the child has a normal risk of HIV progression and ↓ risk of CNS damage from CMV |
|
H |
the child has a normal risk of HIV progression ↑ risk of CNS damage from CMV |
|
I |
the child has a normal risk of both HIV progression and
CNS damage from CMV |
Scenario 37.
Which of the following
treatments in pregnancy is of proven efficacy and safety in
reducing the risk of vertical
transmission to the fetus?
Option list.
|
A |
acyclovir |
|
B |
CMV vaccine |
|
C |
ganciclovir |
|
D |
HIG |
|
E |
valaciclovir |
|
F |
none of the above |
TOG CPD These derive from the TOG article by Navti et al. The
article is from 2016 and is open-access. Comprehensive review and update of
cytomegalovirus infection in pregnancy.
Comprehensive review and update of
cytomegalovirus infection in pregnancy
Regarding cytomegalovirus (CMV),
1. it is a double-stranded RNA herpes
virus. True False
2. it is the commonest congenital viral
infection in
the developed world. True False
3. prevalence is most common in social class
V. True False
Regarding CMV morbidity,
4. it is the leading genetic cause of
sensorineural deafness. True False
5. maternal infection occurring in the
third
trimester carries the highest risk to
the
fetus. True False
6. previous infection confers complete
future
immunity to the mother. True False
Regarding feto-maternal transmission of
CMV,
7. there is good evidence to suggest
that
gestational age has no apparent influence
on
risk of transmission. True False
8. breastfeeding is a route of transmission.
True False
9. for healthy mature babies, an
infection with
the CMV through breastmilk does not pose
significant danger. True False
10. transmission can be reduced by appropriate
hand washing after nappy changes and
exposure to bodily fluids, avoiding
kissing
young children on mouth and cheeks and
by
avoiding sharing food, drinks or
utensils with
young children. True False
11. primary infection, reactivation and
reinfection
with different CMV strains during
pregnancy
has been shown to lead to congenital
CMV. True False
Regarding maternal CMV in pregnancy,
12. diagnosis of maternal CMV based on
symptoms is reliable with over 70% of
women
presenting with classic symptoms. True False
13. viral reactivation is more common in
HIV
positive pregnant women. True False
Regarding diagnosis of CMV infection in
pregnancy,
14. seroconversion of CMV specific
immunoglobulin G (IgG) in paired acute
and
convalescent sera is diagnostic of a new
acute infection. True False
15. When prepregnancy status is unknown,
detection of immunoglobulin M (IgM)-
specific antibody is diagnostic of
primary infection. True False
16. IgM serology is imprecise for
determining
primary infection as it has been shown
to
remain positive for up to a year
following
acute infection. True False
17. The presence of IgG and IgM CMV
antibodies
with low CMV antibody avidity is
diagnostic
of primary infection. True False
Concerning congenital CMV infection,
18. 85% are asymptomatic at birth. True False
19. 30% of affected infants will develop
neurological sequelae. True False
20. 15% of infants born to mothers with
recurrent
CMV infection are overtly symptomatic. True False
TOG. Volume
18, Issue 4 October 2016 Pages 301–7.
Some of the questions are badly
written – I would expect exam questions to be better.
Regarding cytomegalovirus
(CMV),
1. it is a double-stranded RNA herpes virus. True False
2. it is the commonest congenital viral
infection in the developed world. True False.
3. prevalence is most common in social class
V. True False
Regarding CMV morbidity,
4. it is the leading genetic cause of sensorineural
deafness. True False
5. maternal infection occurring in the 3rd.
trimester carries the highest risk to the fetus. True False
6. previous infection confers complete future
immunity to the mother. True False
Regarding feto-maternal transmission of CMV,
7. there is good evidence to suggest that
gestational age has no apparent influence on risk of transmission. True False
8. breastfeeding is a route of transmission. True False
9. for healthy mature babies, an infection with
the CMV through breastmilk does not pose significant danger. True False
10. transmission can be reduced by appropriate
hand washing after nappy changes and exposure to bodily fluids, avoiding
kissing young children on mouth and cheeks and by avoiding sharing food, drinks
or utensils with young children. True False
11. primary infection, reactivation and
reinfection with different CMV strains during pregnancy has been shown to lead
to congenital CMV. True False
Regarding maternal CMV in pregnancy,
12. diagnosis of maternal CMV based on symptoms is
reliable with over 70% of women presenting with classic symptoms. True False
13. viral reactivation is more common in HIV
positive pregnant women. True False
Regarding diagnosis of CMV infection in pregnancy,
14. seroconversion of CMV specific immunoglobulin
G (IgG) in paired acute and convalescent sera is diagnostic of a new acute
infection. True False
15. When prepregnancy status is unknown,
detection of immunoglobulin M (IgM)- specific antibody is diagnostic of primary
infection. True False
16. IgM serology is imprecise for determining
primary infection as it has been shown to remain positive for up to a year following
acute infection. True
17. The presence of IgG and IgM CMV antibodies
with low CMV antibody avidity is diagnostic of primary infection. True False
Concerning congenital CMV infection,
18. 85% are asymptomatic at birth. True False
19. 30% of affected infants will develop
neurological sequelae. True False
20. 15% of infants born to mothers with recurrent
CMV infection are overtly symptomatic.
True False
53. Montgomery
& consent.
Abbreviations.
BMA: British
Medical Association.
GMC: General
Medical Council.
Question 1.
Which, if any, of the following statements is most accurate?
Lead-in
|
A |
The
Montgomery ruling largely replaces the Bolam ruling |
|
B |
The Montgomery ruling largely replaces the Chester
ruling |
|
C |
The Montgomery ruling largely replaces the Sidaway
ruling |
|
D |
The Montgomery ruling is being contested in the
European Court by the GMC as it infringes the rights of doctors |
|
E |
The Montgomery ruling is being contested in the
European Court by the BMA as it infringes the rights of doctors |
Question
2.
Which, if any, of the following statements are true? This is not
a true EMQ as > 1 of the answers may be correct.
Lead-in
|
A |
the
level of risk, however small, must be disclosed if a patient requests it |
|
B |
the level of risk of damage from a procedure need not
be disclosed if < 1% |
|
C |
the level of risk of damage from a procedure need not
be disclosed if < 10% |
|
D |
a material risk is one that would be reflected in
damages > £100,000 if negligence were proved in court |
|
E |
a material risk is one that would be reflected in
damages > £1,000,000 if negligence were proved in court |
|
F |
a material risk is one that involves anatomical damage,
not emotional or psychological |
|
G |
a material risk is one that a reasonable person in the
patient’s situation would be likely to regards as significant |
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