Tutorial 16 February 2012

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Tonight's essays and EMQ are below.
I suspect that there could be an essay from the Maternal Mortality Report.
Sepsis is obviously something you need to know, the definitions and the main direct and indirect causes. But the Ten Top Recommendations or the key points in the "Back to Basics" chapter would make perfect essays. And would be killers if you did not know them.
I put in primary amenorrhoea to remind you to have paediatric gynae topics on your last-minute revision list.
Vault prolapse is one of those very technical essays that is more appropriate for a sub-specialty exam, but it came in  2005 and 2008. There was a joint guideline with the British Society of Urogynae in 2007. You would not remember the details if you are not a sub-spec trainee, so it is another for last-minute revision.
Vulval cancer heads my list of hot topics as far as cancer is concerned. I am half-way through writing an answer that should give you all you need, so send me your version and I'll e-mail it.

A girl of 15 is referred to the gynaecology clinic. She is concerned because she has not started to menstruate although all her friends have.

1. Justify the history you will take.                            6 marks

2. Justify the investigations you will arrange.              6 marks

3. Justify your management                                       8 marks

Outline the key features of the advice given in the “Back to basics” section of the recent Maternal Mortality Report.  

A 73-year-old woman is referred with vault prolapse 5 years after hysterectomy.

1. Discuss the steps that can be taken during and after hysterectomy to reduce the risk of vault prolapse.                                          4 marks

2. Justify the history you will obtain.       4 marks

3. Evaluate the management options.  12 marks               

With regard to vulval cancer.

1. critically evaluate screening.                                                       2 marks.

2. outline the FIGO staging system.                                                6 marks.

3. critically evaluate the modern approach to management.            12 marks.

Antepartum haemorrhage.

Lead-in.

The following scenarios relate to APH.

Pick one option from the option list.

Each option can be used once, more than once or not at all.

Abbreviations.

ART:      assisted reproduction technology

FGR:      fetal growth restriction

GTG:     Green-top guideline no 62

PET:       pre-eclampsia

Option list.

A.        genital tract bleeding ≥ 500 ml. from 24 weeks until the delivery of the baby

B.        genital tract bleeding ≥ 500 ml. from 24 weeks until the delivery of the placenta.

C.        genital tract bleeding ≥ 500 ml. from 24 weeks, or earlier if the baby is live-born, until the delivery of the baby.

D.        1

E.         2

F.         3

G.       4

H.        5

I.          6

J.          7

K.        8

L.         9

M.      10

N.       15

O.       20

P.        30

Q.       50

R.        100

S.         500

T.         1,000

U.       true

V.        false

W.      none of the above

Scenario 1.

What is the definition of APH?

Scenario 2.

What is the upper limit in ml. for minor APH

Scenario 3.

What is the upper limit in ml. of major haemorrhage

Scenario 4.

What is the % risk of recurrence after 1 abruption?

Scenario 5.

What is the % risk of recurrence after 2 abruptions?

Scenario 6.

What is the major risk factor for placental abruption.

Scenario 7

List 10 risk factors for placental abruption.

Scenario 8

List 6 risk factors for placenta previa.

Scenario 9

In what % of pregnancies does APH occur?

Scenario 10

With regards to steps that can be taken to reduce the incidence of APH, what things would you include in an essay?

Tutorial 13 February 2012

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Tonight's tutorial was mainly on oncology by Suku George.
It is great to have an expert - things we would need to think about or look up are on the tip of his tongue.
It was also salutary to have him tell us that he does not remember every detail of staging.
This makes it imperative that you revise this thoroughly in the days before the exam.
You can forget it forever as soon as the exam is over, but you need to pick up the marks in the exam.
We had a few minutes at the end so did an essay plan:

Critically evaluate the management of thrombocytopenia in pregnancy.

There will be a tutorial as usual on Thursday and next Monday.

On Tuesday 21st. there is an extra tutorial on uro-gynaecology by Ahmed Yassin.

This will be at Stepping Hill hospital and will only be available as a podcast.

Then on Thursday the 23rd. there will be a tutorial on medical statistics by Julie Morris.

To get the full benefit, you need to work your way through her two on-lone tutorials on basic statistics.

http://www.south.manchester.ac.uk/medicalstatistics/information.asp.

Tutorial 9 February 2012

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Tonight's essays.

You see a 25-year-old primigravida at 30 weeks’ gestation in the antenatal clinic after referral by the community midwife who feels that the uterus is large-for-dates.

1. Justify your immediate management.                                       6 marks.

2. Justify the management of the remainder of the pregnancy.        4 marks

3. Justify the management of the delivery.                                    6 marks

4. Justify the advice you will give post-delivery.                              4 marks     

A woman opts for HIV screening when she books at 8 week’s gestation in her first pregnancy. The result is +ve.

1. Justify your immediate management.       4 marks

2. Justify your management of the rest of the pregnancy, the delivery and the puerperium.                                              14 marks

3.  Justify the management of the neonate.   2 marks              

A primigravida collapses 1 hour after normal vaginal delivery.

1. Critically evaluate the differential diagnosis of maternal collapse.         6 marks.

2. How may impending maternal collapse be recognised.                       4 marks.

3. Critically evaluate the management of this woman.                           10 marks.

Critically evaluate alternatives to oestrogen HRT in the management of the menopause.  

Tonight's EMQ.

     

Lead-in.

The following scenarios relate to parvovirus infection

Pick one option from the option list.

Each option can be used once, more than once or not at all.

Abbreviations.

GOVRIP:        Guidance on Viral Rash in Pregnancy. HPA. 2011

                         http://www.hpa.org.uk/webc/HPAwebFile/HPAweb_C/1294740918985

HPA:               Health Protection Agency

PSVMCA:      peak systolic velocity middle cerebral artery.

PvB19:            parvovirus B19

PvIgG:            parvovirus B19 IgG

PvIgM:           parvovirus B19 IgM

Option list.

There is none: make up your own answers!

Scenario 1.

What type of virus is parvovirus?

Scenario 2.

Is the title B19 something to do with the American B19 bomber, its potentially devastating bomb load and the comparably devastating consequences of the parvovirus on human erythroid cell precursors?

Scenario 3.

PVB19 in the UK occurs in mini-epidemics at 3 – 4 year intervals, usually during the summer months.

Scenario 4.

Which animal acts as the main reservoir for infection?

Scenario 5.

What percentage of UK adults are immune to parvovirus infection?

Scenario 6.

What names are given to acute infection in the human?

Scenario 7.

What is the incubation period for parvovirus infection?

Scenario 8

What is the duration of infectivity for parvovirus infection?

Scenario 9.

What are the usual symptoms of parvovirus infection in the adult?

Scenario 10.

What is the incidence of parvovirus infection in pregnancy?

Scenario 11.

How is recent infection diagnosed?

Scenario 12.

How long does PvIgM persist and why is it important?

Scenario 13.

What is the rate of vertical transmission of parvovirus infection?

Scenario 14.

Are women with parvovirus infection who are asymptomatic less likely to pass the virus to their fetuses?

Scenario 15.

To what degree is parvovirus infection teratogenic?

Scenario 16.

What proportion of pregnancies infected with parvovirus are lost?

Scenario 17.

What is the timescale for the onset of hydrops?

Scenario 18.

Laboratories are advised to retain bloods obtained at booking for at least 2 years for possible future reference. True or false?

Scenario 19.

What ultrasound features would trigger consideration of cordocentesis?

Scenario 20.

Must suspected parvovirus infection be notified to the authorities?

Scenario 21.

Possible parvovirus infection does not need to be investigated after 20 week’s gestation.

Scenario 22

If serum is sent to the laboratory from a woman with a rash in pregnancy for screening for rubella, the laboratory should automatically test for parvovirus infection too.

 

Tutorial 6 February 2012

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Tonight's essays were:

1. A woman is referred after her third consecutive miscarriage at 10 weeks.

1. outline the key features in the history you will take.     4 marks

2. list the main causes of recurrent miscarriage.              4 marks

3. critically evaluate the investigations you will arrange.   6 marks

4. critically evaluate the available treatments for unexplained recurrent miscarriage.    6 marks   

2. A primigravid woman works in a nursery where there is an outbreak of parvovirus infection. The gestation is 10 weeks.

Critically evaluate the management.

3. With regard to choriocarcinoma.

Outline the factors influencing prognosis.    

Outline the key aspects of treatment.

4. Critically evaluate screening for chlamydia.          

There were two related EMQs.

Obstetric cholestasis. (OC). Definition.

Lead-in.

The following scenarios relate to the definition.

Pick one option from the option list.

Each option can be used once, more than once or not at all.

Abbreviations.

gamma GT: gamma-glutamyl transferase

GTG:      RCOG’s Green-top Guideline No. 43. April 2011.

OC:         obstetric cholestasis.

Option list.

A.             true

B.             false

C.             don’t be daft

D.             pruritus of pregnancy with no other explanation which is associated with abnormal LFTs, raised bile acids and pale stools, all of which resolve postnatally

E.              pruritus of pregnancy with no other explanation which is associated with abnormal LFTs, ± raised bile acids and pale stools, all of which resolve postnatally

F.              pruritus of pregnancy with no other explanation which is associated with abnormal LFTs, ± raised bile acids, all of which resolve postnatally

G.            pruritus of pregnancy with no other explanation which is associated with abnormal LFTs (using pregnancy-specific ranges), ± raised bile acids and pale stools, all of which resolve postnatally

H.             pruritus of pregnancy with no other explanation which is associated with abnormal LFTs (using pregnancy-specific ranges), ± raised bile acids, all of which resolve postnatally

I.               levels do not usually rise in pregnancy

J.               mostly originates in the placenta

K.             levels vary with the time of day

L.              no information in the GTG

M.           none of the above

Scenario 1.

The international definition of OC was agreed at a conference in Tokyo in 1985.

Scenario 2.

What is the GTG’s definition of OC?

Scenario 3.

Levels of bile acids commonly rise significantly after meals making fasting levels mandatory for diagnosis.

Scenario 4.

The upper limit of normal for transaminases, gamma GT and bile acids is about 20% lower in pregnancy.

Scenario 5.

Liver function tests become abnormal as soon as the pruritus is noted.

Scenario 6.

What is the overall prevalence in Eskimos?

Scenario 7.

What is the incidence of pruritus in pregnancy?

 

Obstetric cholestasis. (OC). Prevalence.

Lead-in.

The following scenarios relate to the prevalence of OC.

Pick one option from the option list.

Each option can be used once, more than once or not at all.

Abbreviations.

GTG:     RCOG’s Green-top Guideline No. 43. April 2011.

OC:        obstetric cholestasis.

Option list.

A.        0.1%

B.        0.5%

C.        0.7%

D.        1 – 1.2%

E.         1.2% to 1.5%

F.         1.5 – 2%

G.       2.4%

H.        3 – 3.5%

I.          5%

J.          7%

K.        15%

L.         white

M.      brown

N.       blue-green

O.       red-brown, striped

P.        no information in the GTG

Q.       none of the above

Scenario 1.

What is the overall prevalence in the UK population?

Scenario 2.

What is the overall prevalence in the Indian and Pakistani Asian populations?

Scenario 3.

What is the overall prevalence in Scandinavia?

Scenario 4.

What is the overall prevalence in Chile?

Scenario 5.

What is the overall prevalence in Araucanian Indians?

Scenario 6.

What is the overall prevalence in Eskimos?

Scenario 7.

What is the incidence of pruritus in pregnancy?

Scenario 8.

What colour of eggs do Araucanian chickens lay?

Tutorial 2 February 2012

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Tonight's EMQ was:

Mode of inheritance.

Lead-in.

The following questions relate to the mode of inheritance.

For each question, choose the answer from the option list that best matches. Each option can be used once, more than once or not at all.

Comment.

You are expected to know a lot of basic genetics and it is hard to remember all the details. A list to go over in the days before the exam makes sense. Use this one and add anything else you can think of – and let me know of your additions so I can add them to this list. You will note that I have made a few additions since the tutorial.

List of questions.

1.         achondroplasia.

2.         adreno-genital syndrome.  

3.         Adult polycystic kidney disease.

4.         androgen insensitivity syndrome.  

5.         Angelman syndrome.  

6.         Apert syndrome.

7.         Becker muscular dystrophy.

8.         Cavanan syndrome.

9.         Charcot-Marie-Tooth disease.

10.     Cri-du-chat syndrome.

11.     Dandy-Walker syndrome.  

12.     Down’s syndrome.  

13.     Duchenne muscular dystrophy.  

14.     Edward’s syndrome.  

15.     Ehlers-Danlos syndrome.  

16.     Fitz-Hugh-Curtis syndrome

17.     Fragile X syndrome.  

18.     Glucose-6-phosphate dehydrogenase deficiency.  

19.     Haemochromatosis.

20.     Haemosiderosis.

21.     haemophilia A:  

22.     haemophilia B:  

23.     Huntington’s disease.

24.     Juvenile polycystic kidney disease.

25.     Klinefelter’s syndrome.

26.     Lynch syndrome (HNPCC).  

27.     Marfan’s syndrome.  

28.     Mayer-Rokitansky-Kuster-Hauser syndrome:  

29.     Myotonic dystrophy.

30.     Neurofibromatosis.

31.     Noonan syndrome.  

32.     Patau’s syndrome.

33.     Perrault syndrome.  

34.     Phenyketonuria.

35.     Prader-Willi  

36.     Potter’s syndrome.  

37.     Sickle cell disease.  

38.     Syndrome X.

39.     Tay-Sach’s disease.  

40.     Thalassaemia.  

41.     Triple X syndrome.  

42.     Turner’s syndrome

43.     Swyer’s syndrome.  

44.     VACTERL.  

45.     von Willebrand’s disease.  

46.     A mother has spina bifida. What is the risk of a child being affected?   

47.     A mother has had a child with spina bifida, what is the risk of the next child being affected? ~  

48.     A mother has had two children with spina bifida. What is the risk of the next child being affected?  

49.     A mother has grand-mal epilepsy. What is the risk of her child having epilepsy?  

50.     A mother and her partner both have grand-mal epilepsy. What is the risk of their child having epilepsy?  

51.     A mother has insulin-dependent diabetes mellitus. What is the risk of a child being affected?  

52.     A mother has congenital heart disease. What is the risk of a child being affected?

53.     A mother takes lithium for bi-polar disorder throughout her pregnancy. What is the risk of the child having congenital heart disease?

54.     A mother has a nuchal translucency scan at 11 weeks. The result is 6 mm. What is the risk of the fetus having congenital heart disease?

The essays were:

 

Essays 2 February 2012

A primigravid woman attends the antenatal booking clinic at 5 weeks’ gestation. She smells strongly of alcohol. She admits to consuming at least ½ bottle of vodka each day.

1. Critically evaluate the public health advice available in the UK about alcohol and pregnancy.         4 marks.

2. Critically evaluate screening for alcohol abuse in pregnancy.                                                         4 marks.

3. Critically evaluate the risks to the fetus and child of the mother who abuses alcohol in pregnancy.  6 marks.

4. Justify the management you would arrange for this patient.                                                            6 marks.

With regard to anti-phospholipid syndrome (APS):

1. outline how the diagnosis is made.                                            4 marks.

2. outline the clinical manifestations of APS.                                6 marks.

3.  outline the management of APS in relation to pregnancy. 10 marks.

It is Saturday morning.  You are the on-call SpR for gynaecology and have been asked for help by the locum Registrar in A&E. A man has returned from Africa on a surprise visit home. On arrival he cut his finger on a kitchen knife and has attended A&E for treatment.  He is accompanied by his wife. His finger has been cleaned and two sutures have been inserted. Prior to treatment he mentioned that he was found to be HIV+ve as a result of extra-marital heterosexual activity in Africa and was started on anti-retroviral therapy there. He refuses to disclose his HIV status to his wife as she would “go mad” if she were to discover his infidelity. She has asked for contraceptive advice as he was not due to return for several months and she stopped contraception when he left 3 months before. The A&E Consultant has gone out to a major road traffic accident and is not expected to be available for about an hour. The husband is not prepared to await his return. The sexually-transmitted disease STD clinic is closed and will not open until Monday. You have spoken to your Consultant who has said he doesn’t want to know and that you have to “get on with it”. Outline and justify your management.

Critically evaluate palliative treatment in gynaecological oncology.

Tutorial 30 January 2012

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Tonight's topics were:

Maternal Mortality.

Lead-in.

The following scenarios relate to maternal mortality.

Pick the option that best answers the task in each scenario from the option list.

Each option can be used once, more than once or not at all.

Option List.

A.   Death of a woman during pregnancy and up to 6 weeks later, including accidental and incidental causes.

B.    Death of a woman during pregnancy and up to 6 weeks later, excluding accidental and incidental caused.

C.    Death of a woman during pregnancy and up to 52 weeks later, including accidental and incidental causes.

D.   Death of a woman during pregnancy and up to 52 weeks later, excluding accidental and incidental causes.

E.    A pregnancy going to 24 weeks or beyond.

F.    A pregnancy going to 24 weeks or beyond + any pregnancy resulting in a live-birth.

G.   Maternal deaths per 100,000 maternities.

H.   Maternal deaths per 100,000 live births.

I.      Direct + indirect deaths per 100,000 maternities.

J.     Direct + indirect deaths per 100,000 live births.

K.    Direct death.

L.     Indirect death.

M. Early death.

N.   Late death.

O.   Extra-late death.

P.    Fortuitous death.

Q.   Coincidental death.

R.    Accidental death.

S.    Maternal murder.

T.    Not a maternal death.

U.   Yes

V.   No.

W. I have no idea.

X.    None of the above.

Abbreviations.

MMR:      Maternal Mortality Rate.

MMRat:  Maternat Mortality Ratio.

SUDEP:    Sudden Unexplained Death in Epilepsy.            

Option list.

Scenario 1.

What is a Maternal Death?

Scenario 2.

A woman dies from a ruptured ectopic pregnancy at 10 weeks’ gestation. What kind of death is it?

Scenario 3.

A woman dies from a ruptured appendix at 10 weeks’ gestation. What kind of death is it?

Scenario 4.

A woman dies from suicide at 10 weeks’ gestation. What kind of death is it?

Scenario 5.

A woman with a 10-year-history of coronary artery disease dies of a coronary thrombosis at 36 weeks’ gestation. What kind of death is it?

Scenario 6.

A woman has gestational trophoblastic disease, develops choriocarcinomas and dies from it 24 months after the GTD was diagnosed and the uterus evacuated. What kind of death is it?

Scenario 7

A woman develops puerperal psychosis from which she makes a poor recovery. She kills herself when the baby is 18 months old. What kind of death is it?

Scenario 8

A woman develops puerperal psychosis from which she makes a poor recovery. She kills herself when the baby is 6 months old. What kind of death is it?

Scenario 9

What is a “maternity”.

Scenario 10

What is the definition of the Maternal Mortality Rate?

Scenario 11

What is the Maternal Mortality Ratio?

Scenario 12

A woman is diagnosed with breast cancer. She has missed a period and a pregnancy test is +ve. She decides to continue with the pregnancy. The breast cancer does not respond to treatment and she dies from secondary disease at 38 weeks. What kind of death is it?

Scenario 13

A woman who has been the subject of domestic violence is killed at 12 weeks’ gestation by her partner. What kind of death is it?

Scenario 14

A woman is struck by lightning as she runs across a road. As a result she falls under the wheels of a large lorry which runs over abdomen, rupturing her spleen and provoking placental abruption. She dies of haemorrhage, mostly from the abruption. What kind of death is it?

Scenario 15

A woman is abducted by Martians who are keen to study human pregnancy. She dies as a result of the treatment she receives. As this death could only have occurred because she was pegnant, is it a direct death?

Scenario 16

Could a maternal death from malignancy be classified as “Direct”.

Scenario 17

Could a maternal death from malignancy be classified as “Indirect”.

Scenario 18

Could a maternal death from malignancy be classified as “Coincidental”?

 

30^th. January 2012

Essays.

With regard to smoking in pregnancy, critically evaluate:

1. risks to the mother,     4 marks

2. risks to the fetus,        4 marks

3. risks to the neonate,   4 marks

4. steps to reduce risks.  8 marks

A woman attends the antenatal clinic at 36 weeks. She had read an article in a woman’s magazine about the merits of umbilical cord blood banking and would like to have this done.

1. Justify the history you will take.                     4 marks

2. Justify the investigations you will arrange.    2 marks

3. Justify your management.                           14 marks      

You have been asked to write a protocol for the diagnosis and management of umbilical cord prolapse.

1. Justify the steps you will take.                                        6  marks

2. Justify the key advice you will include in the protocol. 14 marks 

You are the sPR in the fertility clinic. A couple have been referred by their General Practitioner after basic investigation of their three years of infertility. She has never been pregnant, he has never made a partner pregnant.

1. Justify the history you will take.                              4 marks

2. Justify the investigations you will arrange.             6 marks

3. Outline the management and available options.  10 marks