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Tonight we had the privilege of the company of Varsha Mulik.
She was a consultant in the UK, but has been in Singapore for the past couple of years doing high-powered ultrasound.
She runs the North West MRCOG Written course, which has been taking place this week.
I felt that having her in the country was too good an opportunity to miss, so I decided we should have a couple of essays that played to her expertise.
The essays we discussed were:
1. With regard to
nuchal translucency.
a. What is nuchal translucency, how is it
measured and what are the important values?
6 marks
b. When is it measured and why are other times
not used? 4
marks
c. Critically evaluate the uses and
implications of NT measurement. 10 marks.
2. With regard to
cell-free fetal DNA (cffDNA).
a. what is cffDNA? 4
marks
b. detail the current uses of cffDNA in the
NHS. 6 marks
c. discuss the potential uses of cffDNA. 10 marks
3. Critically
evaluate Down’s syndrome screening.
We then had two EMQs.
Obstetric cholestasis. (OC). 1.
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?
Obstetric cholestasis. (OC). 2.
Lead-in.
The following scenarios relate to the definition and
diagnosis.
Pick one option from the option list.
Each option can be used once, more than once or not at
all.
Some of the answers are more MCQ than EMQ, i.e. “true” or
“false”.
Abbreviations.
gamma GT: gamma-glutamyl transferase
GTG: RCOG’s
Green-top Guideline No. 43. April 2011.
OC: obstetric
cholestasis.
Suggested reading.
The GTG is “must read”. It is also dealt with in MCQ paper 1,
question 41. I don’t think you need to read anything more.
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.
What is the incidence of pruritus in pregnancy?
Scenario 4.
Hepatitis B and C, but not
hepatitis A, may cause pruritus and abnormal LFTs in pregnancy.
Scenario 5.
Infection with the Ebstein Barr
virus may cause pruritus and abnormal LFTs in pregnancy.
Scenario 6.
The cytomegalovirus may cause
pruritus and abnormal LFTs in pregnancy.
Scenario 7.
The herpes zoster virus may
cause pruritus and abnormal LFTs in pregnancy.
Scenario 8.
Chronic active hepatitis and
secondary biliary cirrhosis are included in the GTG’s list of conditions to be
considered in the differential diagnosis.
Scenario 9.
Bilirubin levels are normally
elevated in the early stages of OC and remain elevated until the condition
resolves after delivery.
Scenario 10.
Liver function tests become abnormal as soon as the
pruritus is noted.
Scenario 11.
Levels of bile acids commonly rise significantly after
meals making fasting levels mandatory for diagnosis.
Scenario 12.
The upper limit of normal for transaminases, gamma GT and
bile acids is about 20% lower in pregnancy.
Scenario 13.
Once a diagnosis of OC has been
made, tests of liver function should not be repeated until the puerperium
Scenario 14.
LFTs should be checked weekly
until they have returned to normal after delivery of the baby in a case of OC.
Scenario 15.
Once a diagnosis of OC has been
made, the activated partial thromboplastin time (APTT) should be measured and a
full coagulation screen done if it is prolonged.
Scenario 16.
Delivery at 37 weeks should be
recommended because of the risk of FDIU in the later weeks of pregnancy.
Scenario 17.
What additional pre-labour
monitoring of fetal welfare is advisable in the third trimester?
Scenario 18.
Prophylactic steroids should be
offered at 28 weeks because of the risk of spontaneous premature labour.
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