Tutorial 30 May 2013

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We started with an EMQ.

EMQ Paper 1, Question 1.

Lead-in.

The following scenarios relate to early pregnancy.

For each, select the diagnosis you most want to exclude.

Pick one option from the option list.

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

Scenario 1.

A 35-year-old primigravida is seen in the EPU with vaginal bleeding and severe left iliac fossa pain. The pregnancy occurred after four cycles of IVF and embryo transfer was performed six weeks ago. Her β-hCG is >1,000 iu/l. An ultrasound scan showed an intra-uterine pregnancy of an appropriate size for the gestation. Normal fetal heart activity was noted. No adnexal masses were seen.

Scenario 2.

A 25-year-old woman with known PCOS is seen in the early pregnancy unit after an episode of slight vaginal bleeding. Her LMP was 10 weeks ago. An ultrasound scan shows an intra-uterine pregnancy with CRL of 6 mm. No fetal heart activity is seen.

Scenario 3.

A GP phones for advice. She is conducting her morning surgery. A nulliparous woman at 6 weeks’ gestation has returned from France where she has enjoyed the local food, particularly unpasteurised soft cheese and pork meats. She has presented with diarrhoea and mild abdominal pain. A β-hCG is 25 iu/l. She is concerned about listeriosis and toxoplasmosis, about which she has read.

Scenario 4.

A 30-year-old parous woman attends the EPU with vaginal bleeding and lower abdominal pain. An ultrasound scan shows a 30 mm. intra-uterine sac but no evidence of fetal heart activity.

Scenario 5.

 A 45-year-old para 6 is admitted to the A&E department with 6 weeks’ amenorrhoea. A β-hCG is positive. She complains of retrosternal pain and has a history of heartburn and acid reflux. Her BMI is 30. She smokes 40 cigarettes daily and has COAD.

Option list.

Complete miscarriage.

Incomplete miscarriage.

Missed miscarriage.

Pregnancy in a uterine horn.

Ectopic pregnancy.

OHSS.

Ovarian torsion.

Ovarian cyst accident.

Hydatidiform mole.

Listeriosis.

Toxoplasmosis.

Crohn’s disease

Ulcerative colitis.

Duodenal ulceration.

Pulmonary embolism.

Pneumothorax.

Coronary thrombosis.

None of the above.

Then we discussed plans for 3 essays.

3	Critically evaluate screening for gynaecological cancer.
4	Cytomegalovirus infection. A woman books at 8 weeks’ gestation in her first pregnancy. She is concerned because she works in a nursery where there has been an outbreak of cytomegalovirus infection. Critically evaluate the management.
5	Audit. You have been asked to perform an audit. Outline the key issues involved in preparing and performing an audit.