Saturday, 4 November 2023

Tutorial Monday 6th. November 2023

 

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1

Jenny Myers. Tutorial. Diabetes.

2

How to prepare. Part 2. What to read. StratOG. TOG CPD. RCOG sample questions. Revision system. Study buddies. Intelligent guessing. Statistics. Urogynae. Other specialist tutorials.

3

EMQ. Cystic fibrosis

4

EMQ. Hepatitis B

5

EMQ. ARRIVE trial

6

SBA. McCune Albright syndrome

 

1.        Jenny Myers. Tutorial. Diabetes.

 2.        How to prepare.

We will give this a quick run-through and I’ll attempt to answer any questions.

 3.        Cystic fibrosis.

There is no option list to make you behave in a model fashion – best technique is to decide the correct answer before looking at the option list.

Scenario 1. A woman is 8 weeks pregnant and a carrier of CF. Her husband is Caucasian. What is the risk of the child having CF?

Scenario 2. A healthy woman attends for pre-pregnancy counselling. Her brother has CF. Her husband is Caucasian and has a negative CF screen. What is the risk of them having a child with CF?

Scenario 3. A healthy woman is a carrier of CF. She attends for pre-pregnancy counselling. Her husband has CF. What is the risk of them having a child with CF?

Scenario 4. A healthy woman attends for pre-pregnancy counselling. Her sister has had a child with CF. What is her risk of being a carrier?

Scenario 5. A woman attends for pre-pregnancy counselling. Her mother has CF.

What is the risk that she is a carrier?

Scenario 6 . A woman attends for pre-pregnancy counselling. Her mother has CF.

The partner’s risk of being a carrier is 1 in X. What is the risk that she will have a child with CF?

Scenario 7. A healthy Caucasian woman is 10 weeks pregnant. Her husband is a carrier of CF. Which test would you arrange?

Scenario 8. A woman attends for pre-pregnancy counselling. She has read about diagnosing CF using cffDNA from maternal blood. Is it possible to test for CF in this way?

Scenario 9. A woman and her husband are carriers of CF. What is the risk of an affected child?

Scenario 10. A woman and her husband are carriers of CF. What can they do to reduce the risk of having an affected child?

Scenario 11. A woman and her husband are carriers of CF. Can CVS exclude an affected pregnancy?

Scenario 12. A woman has CF, her husband is a carrier. What is their risk of an affected child?

Scenario 13. A woman with CF delivers a baby at term. She has been advised not to breastfeed because her breast milk will be protein-deficient due to malabsorption. Is this advice correct?

Scenario 14. A woman with CF delivers a baby at term. She has been advised not to breastfeed because her breast milk will contain abnormally low levels of sodium. Is this advice correct?

 

TOG CPD. 2009. 11. 1. Cystic fibrosis and pregnancy

These are open access so are produced here.

Regarding cystic fibrosis,

1.     there are approximately 8000 people living with this disease in the UK.                     True / False

2.     the main cause of death is liver disease.                                                                      True / False

Women with cystic fibrosis

3.     have an approximately 50% reduced fertility.                                                             True / False

4.     have a life expectancy of approximately 50 years.                                                     True / False

With regard to pregnancy in women with cystic fibrosis,

5.     their babies usually have an appropriate birthweight for their gestational age.      True / False

6.     approximately 70% of babies are born prematurely.                                                True / False

7.     the risk of developing gestational diabetes is higher than in the general population.              True / False

8.     the risk of miscarriage is higher than in the general population.                            True / False

9.     the risk of congenital malformations is similar to that in women who are carriers.             True / False

Women with cystic fibrosis who become pregnant,

10.   have a shortened life expectancy compared with women who do not.                    True / False

If a woman with cystic fibrosis becomes pregnant, the risk of the baby being born with cystic fibrosis

11.   is 50% if the father carries one of the common gene mutations for cystic fibrosis.         True / False

12.   is < 1 in 250 if the father does not carry any of the common CF mutations.                              True / False

During pregnancy, a woman with cystic fibrosis

13.   should be cared for by a multidisciplinary team, including a physician and an obstetrician with a special interest in CF in pregnancy.                                                                                         True / False

14.   should have a GTT if she did not have CF-related diabetes prior to pregnancy. True / False

In pregnant women with cystic fibrosis,

15.   the instrumental delivery rate is approximately 40%.                                               True / False

16.   the use of epidural analgesia during delivery is contraindicated.                            True / False

17.   the risk of poor pregnancy outcome increases if the FEV1 is < 70%.                     True / False

Post- delivery in women with cystic fibrosis

18.   breastfeeding is contraindicated because of the high sodium content of breast milk.         True / False

Which of the following statements about cystic fibrosis are correct?

19.   Menarche in girls with CF occurs at the same time as in unaffected girls.                          True / False

20.   Fertility in women with CF is affected to the same extent as it is in men with CF.      True / False

 

4.        Hepatitis B.

Abbreviations.

GDM:    gestational diabetes mellitus.

HAV:     hepatitis A virus

HBcAg:  hepatitis B core antigen

HBeAg: hepatitis B e antigen     

HBsAg:  hepatitis B surface antigen

HBcAb: antibody to hepatitis B core antigen

HBeAb: antibody to hepatitis B e antigen

HBsAb: antibody to hepatitis B surface antigen

HBIG:    hepatitis B immunoglobulin

HBV:     hepatitis B virus

HCV:     hepatitis C virus

HEV:      hepatitis E virus

HSV:      herpes simplex virus

Question 1.        An asymptomatic primigravida books at 10 weeks. Her partner had an acute HBV

infection 4 months ago. What results on routine blood testing would indicate that she has an acute HBV infection?

Question 2.        An asymptomatic primigravida books at 10 weeks. Her partner had an acute HBV

infection 4 months ago. What results on routine blood testing would indicate that she is immune to the HBV as a result of infection?

Question 3.        An asymptomatic primigravida books at 10 weeks. Her partner had an acute HBV

infection 4 months ago. What results on routine blood testing would indicate that she is immune to the HBV as a result of HBV vaccine?

Question 4.        An asymptomatic primigravida books at 10 weeks. Her partner had an acute HBV

infection 9 months ago. What results on routine blood testing would show that she is a chronic carrier of HBV infection, assuming that she became infected early in the partner’s illness?

Question 5.        Testing shows that he is positive for HBsAg, positive for HBcAb but negative for IgM

 HBcAb. What does this mean in relation to his HBV status?

Question 6.        Testing shows that he is negative for HBsAg, positive for HBcAb and positive for

HBsAb. What does this mean in relation to his HBV status?

Question 7.        How common is chronic HBV carrier status in UK pregnant women?

Question 8.        What is the risk of death from chronic HBV carrier status?

Question 9.        A primigravid woman at 8 weeks gestation is found to be non-immune to HBV. She has

recently married and her husband is a chronic carrier. What should be done to protect her from infection?

Question 10.    A woman is a known carrier of HBV. What is the risk of vertical transmission in the first

trimester?

Question 11.    What is the risk of the neonate who has been infected by vertical transmission

becoming a carrier without treatment?

Question 12.    Should antiviral maternal therapy in the 3rd. trimester be considered for women with

HBeAg or high viral load?

Question 13.    How effective is hepatitis B prophylaxis for the neonate in preventing chronic carrier

status as a result of vertical transmission?

Question 14.    Can a woman who is a chronic HBV carrier breastfeed safely?

Question 15.    Hepatitis B infection is the most dangerous of the viral hepatitis infections in

pregnancy.

Question 16.    A pregnant woman who is not immune to HBV has a partner who is a chronic carrier.

Can HBV vaccine be administered safely in pregnancy?

Question 17.    How long can HBV survive outside the body?

Question 18.    A pregnant woman who is not immune has a partner with acute hepatitis due to HBV.

He cuts his hand and bleeds onto the kitchen table. How should she clean the surface to ensure that she gets rid of the virus?

Question 19.    Is it true that the presence of HBeAg in maternal blood is a particular risk factor for

vertical transmission? Not really a scenario, but never mind!

Question 20.    What does 5 log10 copies /mL mean?

A

> 10 copies / mL

B

> 100 copies / mL

C

> 1,000 copies / mL

D

> 10,000 copies / mL

E

> 100,000 copies / mL

F

this has scared me witless and I am going straight home to complain to my Mum

Question 21.    Which, if any, of the following statements are true about amniocentesis and CVS and

the risk of vertical transmission if the mother is HbsAg+ve?

A

they are contraindicated

B

they should be done with cover with HBIG

C

they should be done with cover with a drug that is  effective for HBV and safe in pregnancy.

D

none of the above

Question 22.    Which, if any, of the following statements are true about treatment in the third

trimester to reduce the risk of vertical transmission?

A

women who are HbsAg+ve should be offered testing for HBV DNA levels in the 3rd. trimester

B

there is no effective treatment for HBV in the 3rd. trimester

C

the risks of treatment for HBV in the 3rd. trimester outweigh the benefits

D

drug treatment for HBV in the 3rd. trimester adds nothing beneficial to the normal use of HBIG + HB vaccination of the neonate

E

none of the above.

Question 23.    Which, if any, of the following drugs is recommended for use in the third trimester to

 reduce the risk of vertical transmission?

A

acyclovir 

B

lamivudine

C

telbivudine

D

tenofovir

Question 24.    Does elective Cs before labour and with the membranes intact reduce the vertical

transmission rate?

Question 25.    Which hepatitis virus normally produces a mild illness, but represents a major risk to

pregnant women, with a mortality rate of up to 5%?

Question 26.    A pregnant woman has a history of viral hepatitis and informs the midwife at booking

that she is a carrier and that she has a significant risk of cirrhosis and has been advised not to drink alcohol. Which is the most likely hepatitis virus?

Question 27.    Which hepatitis virus is an absolute contraindication to breastfeeding after

appropriate treatment of the infected mother and prophylaxis for the baby?

Question 28.    Which hepatitis virus is linked to an increased risk of obstetric cholestasis?

Question 29.    Which, if any, of the following statements is true in relation to HepB and the risk of

GDM?

A

the risk is about the same

B

the relative risk is about 0.1.

C

the relative risk is about 0.2.

D

the relative risk is about 0.5.

E

the relative risk is about 1.2.

F

the relative risk is about 1.5.

G

the relative risk is about 2.0

H

the relative risk is about 3.0

I

the risk is unknown

 

5.        ARRIVE trial.

Abbreviations.

EBL:    estimated blood loss.

IOL:    induction of labour.

SGA:   small for gestational age.

Question 1.   What does the acronym ‘ARRIVE’ mean?

Option list.

A

a randomised review of intravenous ergometrine for the prevention of PPH

B

a randomised review of IVF efficacy

C

a retrospective review of IVF efficacy

D

a randomised review of IOL at term versus expectant management of high-risk pregnancy

E

a randomised review of IOL at 39 weeks versus expectant management of high-risk pregnancy

F

a randomised trial of IOL at term versus expectant management of low-risk pregnancy

G

a randomised trial of IOL at 39 weeks versus expectant management of low-risk pregnancy

H

none of the above

Question 2.   What was the primary outcome of the trial?

Option list.

A

C section and instrumental delivery rates versus the spontaneous delivery rate

B

cost-effectiveness of IVF

C

composite outcome of perinatal death or severe neonatal complications

D

estimated blood loss using low-dose ergometrine versus oxytocin for the 3rd. stage

E

frequency and severity of perineal trauma

F

length of labour

G

maternal satisfaction

H

urinary incontinence severity score at 3 months postpartum

I

none of the above

Question 3.   Which, if any, of the following were the important conclusions of the trial?

Option list.

A

C section and instrumental delivery rates were significantly with IOL at 39/52

B

C section rate but not instrumental delivery rate was significantly with IOL at 39/52

C

instrumental delivery rate but not C section rate was significantly with IOL at 39/52

D

C section and instrumental delivery rates were significantly with IOL at 39/52

E

C section rate but not instrumental delivery rate was significantly with IOL at 39/52

F

instrumental delivery rate but not C section rate was significantly with IOL at 39/52

G

C section and instrumental delivery rates were unchanged

H

IVF was cost-effective

I

IVF was not cost-effective

J

composite perinatal outcome was better with IOL

K

composite perinatal outcome was unchanged with IOL

L

composite perinatal outcome was worse with IOL

M

EBL using low-dose ergometrine versus oxytocin for the 3rd. stage was ↓↓

N

EBL using low-dose ergometrine versus oxytocin for the 3rd. stage was ↓↓ but with ↑↑ BP

O

frequency and severity of perineal trauma with IOL

P

length of labour was ↑↑ with IOL

Q

maternal satisfaction was higher with IOL

R

urinary incontinence at 3 months was reduced by IOL

S

none of the above

 

6.        McCune Albright syndrome.

McCune-Albright syndrome.

Abbreviations.

CPP:      central precocious puberty.

MCA:    McCune Albright syndrome.

PFD:      polyostotic fibrous dysplasia.

PP:         precocious puberty.

Scenario 1.    Which, if any, of the following are components of the classical triad of MCA?

Option List

A

albinism

B

“cafè Cubano” spots

C

“Coast of California” pigmented areas

D

lentigo

E

macroorchidism

F

osteomalacia

G

polyostotic fibrous dysplasia

H

precocious puberty

I

premature menopause

J

primary amenorrhoea

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

Option List

A

it is an example of central primary amenorrhoea

B

it is an example of central secondary amenorrhoea

C

it is an example of central precocious puberty

D

it is an example of peripheral primary amenorrhoea

E

it is an example of peripheral secondary amenorrhoea

F

it is an example of peripheral precocious puberty

G

none of the above

Scenario 3.    Which, if any, of the following are believed to be true in relation to the abnormality of

onset of puberty associated with MCA?

Option List

A

it is due to abnormal FSH production

B

it is due to abnormal LH production

C

it may be due to abnormal androgen production

D

it may be due to abnormal oestrogen production

E

it is linked to ovarian cysts with malignant potential

F

none of the above

Scenario 4.    Which, if any, of the following are true in relation to polyostotic fibrous dysplasia?

Option List

A

polyostotic means resembling parrot bone

B

polyostotic means resembling pigeon bone

C

polyostotic means affecting long bones

D

fibrous dysplasia refers to replacement of marrow by fibrous tissue

E

PFD is a variant of osteomalacia

F

PFD may be unilateral

G

PFD is associated with a 1% risk of malignancy

Scenario 5.    Which, if any, of the following are true in relation to MCA?

Option List

A

hyperthyroidism is common

B

hypothyroidism is common

C

thyroid function is similar to those without MCA

Scenario 6.    Which, if any, of the following are true in relation to MCA?

Option List

A

excess growth hormone production  is common

B

inadequate growth hormone production is common

C

growth hormone production is similar to those without MCA

Scenario 7.    Which, if any, of the following is true in relation to MCA?

Option List

A

inheritance is autosomal dominant

B

inheritance is autosomal recessive

C

inheritance is X-linked dominant

D

inheritance is X-linked recessive

E

inheritance is multifactorial

F

it is not a hereditary disorder

G

it is not genetic

H

none of the above

Scenario 8.    Which, if any, of the following are true in relation to MCA?

Option List

A

renal artery stenosis is more common

B

renal cortex wasting is more common

C

renal phosphate wasting is more common

D

renal waisting is more common

E

none of the above.

Scenario 9.    Approximately what % of children born to women with MCAS will have MCAS?

Option List

A

0

B

1 in 105 - 106

C

1 in 104

D

1 in 100

E

1 in 50

F

1 in 10

G

1 in 2

H

All

 

TOG includes MCAS in CPD Questions for volume 14, number 2, 2012, which are open access, so reproduced here. There are only two questions on MCAS. Note that the second includes CPP.

McCune–Albright syndrome

1. is caused by activating mutations of the GNAS1 gene.                                            True / False

2. is characterised by polyostotic fibrous dysplasia, café-au-lait spots and CPP.      True / False

 

 

 

 


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