Thursday, 21 August 2014

Tutorial 18 August 2014

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25
EMQ. Diabetes in pregnancy
26
EMQ. Drugs in pregnancy 2
27
EMQ. Ectopic & early pregnancy
28
EMQ. Endometrial cancer
29
EMQ. Epidural anaesthesia
30
EMQ. GpB Streptococcus 1
75
A woman of 38 is referred to the gynaecology clinic as the tail of her IUCD could not be seen when she recently had a routine cervical smear.
1.  Outline the history you will take.                      6 marks.
2.  Justify the investigations you will arrange.         4 marks.
3.  Justify your management.                               10 marks.
76
A healthy 30-year-old woman with blood group Rh negative is found to have rhesus D antibodies at booking at 8 weeks.
Critically evaluate the management.
77
You are the SpR in the gynaecology clinic. You see a patient referred for management of premenstrual syndrome.
1. Define PMS and its grades of severity.           4 marks.
2. Outline the investigations you will arrange.      6 marks.
3. Critically evaluate the management options.  10 marks
78
With regard to adhesions that result from abdominal surgery.
1. Outline the incidence and possible adverse consequences of adhesion formation after surgery.                                                                                  8 marks.
2. How may the incidence of surgical adhesions be reduced? 12 marks.

Diabetes in pregnancy.
Lead-in.
The following scenarios relate to diabetes in pregnancy.
For each, select the action from the option that best fits the scenario.
Pick one option from the option list.
Each option can be used once, more than once or not at all.

Abbreviations.
ACE:       angiotensin converting enzyme.
ARA:      angiotensin II receptor antagonist.
GDM:    gestational diabetes mellitus.
OGTT:   oral glucose tolerance test.

Option list.
advise postponement of pregnancy.
normal antenatal care.
refer to a joint diabetic / antenatal clinic.
refer to the next joint diabetic / antenatal clinic.
refer for a diabetic opinion.
refer to a nephrologist.
refer to a clinical psychologist.
arrange referral for screening for diabetic retinopathy.
screen for microalbuminuria.
stop ACE inhibitor / ARA drugs and arrange for safer substitutes.
advise to continue statin.
asvise to stop statin.
prescribe folic acid 5mg. daily and advise HbA1c , 6.1%, if not associated with untoward symptoms.
stop oral hypoglycaemic drug and start insulin.
discuss pros and cons of oral hypoglycaemic drug, but allow her to continue to take it.
arrange fasting plasma glucose level and repeat monthly.
arrange HbA1c assay and repeat monthly.
arrange a 75 gram OGTT now.
arrange a 75 gram OGTT at 16 weeks
arrange a 75 gram OGTT at 28 weeks.
arrange a 100 gram OGTT now.
arrange a 100 gram OGTT at 16 weeks
arrange a 100 gram OGTT at 28 weeks.
Resign, buy a yacht and sail to Bali.
none of the above

Scenario 1.
A woman with type II diabetes attends for pre-pregnancy counselling. Her HbA1c is 10.6 %. Her health is good. She last had screening for retinopathy 8 months ago. What is the most important advice you will give?
Scenario 2.
A woman with type II diabetes attends for pre-pregnancy counselling. Her HbA1c is 5.4 %. She last had screening for retinopathy 8 months ago. What advice will you give about retinopathy screening?
Scenario 3.
A 35 year-old para 1 with type II diabetes attends for pre-pregnancy counselling. Her health is good. Her HbA1c is 4.8%. Her pregnancy was 2 years ago and was normal. The baby weighed 3.5 kg. at 40 weeks and is healthy. Her serum creatinine is 125 micromol/ litre.
Scenario 4.
A 35 year-old para 1 with type II diabetes attends for pre-pregnancy counselling. Her health is good. Her HbA1c is 4.8%. Her pregnancy was 2 years ago and was normal. The baby weighed 3.5 kg. at 40 weeks and is healthy. Her GFR is 60 ml./minute. What advice will you give about referral to a nephrologist?
Scenario 5.
A 35 year-old para 1 with type II diabetes attends for pre-pregnancy counselling. Her health is good. Her blood sugar levels are well controlled with diet and metformin. What advice will you give about metformin?
Scenario 6.
A 38 year-old woman attends the booking clinic at 8 weeks. GDM was diagnosed at 34 weeks in the 1st. pregnancy. Despite good glycaemic control, the baby weighed 5.2 kg. and required Caesarean section for delivery after a prolonged 2nd. stage. She is keen to have the earliest possible diagnosis of recurrence.
Scenario 7
A 38 year-old woman attends the booking clinic at 8 weeks. GDM was diagnosed at 34 weeks in the 1st. pregnancy. Despite good glycaemic control, the baby weighed 5.2 kg. and required Caesarean section for delivery after a prolonged 2nd. stage. She is keen to have the earliest possible diagnosis of recurrence but has needle phobia and an aversion to self-monitoring.
Scenario 8
A 25-year-old primigravida books at 10 weeks. Her health is good but her BMI is 28. What screening for hyperglycaemia will you arrange.
Scenario 9
A healthy para 1 books at 10 weeks. She takes a statin because of elevated cholesterol and triglyceride levels. Her blood pressure is 130/85. Otherwise she is well.

Drugs in Pregnancy. 2.
Lead-in.
The following scenarios relate to some common drugs used in pregnancy.
Pick one option from the option list. Each option can be used once, more than once or not at all.
Abbreviations.
BNF.      British National Formulary
eMC.     electronic Medicines Compendium
NSAID.  non-steroidal anti-inflammatory drug.

Option list.
I have not given one to make you think! And, in the exam, you should be deciding your answer before you check the option list.
Scenario 1.
What is the generic name for Prostin?
Scenario 2.
What kind of drug is Prostin?
Scenario 3.
What is the generic name for Misoprostol?
Scenario 4.
What kind of drug is Misoprostol?
Scenario 5.
What is the generic name for Gemeprost?
Scenario 6.
What kind of drug is Gemeprost?
Scenario 7
What is the generic name for Mifepristone?
Scenario 8
What king of drug is Mifepristone?
Scenario 9
What are the constituents of a 1 ml. ampoule of Syntometrine?
Scenario 10
What is the generic name for Carbetocin?
Scenario 11
What kind of drug is Carbetocin?
Scenario 12
What is the generic name for Hemabate?
Scenario 13
What kind of drug is Hemabate?
Scenario 14
What is the generic name for Atosiban?
Scenario 15
What kind of drug is atosiban?
Scenario 16
What if the generic name for Cervagem?
Scenario 17
What kind of drug is Cervagem?
Scenarion 18
What is the cost of 1mg. of Prostin E2 gel and what are its storage requirements?
Scenarion 19
What is the cost of a 1mg. Gemeprost pessary and what are its storage requirements?
Scenarion 20
What is the cost of 200 mcg. of misoprostol and what are its storage requirements?

Ectopic & early pregnancy. NICE CG154.

Lead-in.
The following scenarios relate to ectopic and early pregnancy.
Some of the questions are MCQs, with “True” or “False”, not EMQs.
Some want you to write a list of facts.
There is no option list – write what you think the answer should be.

Abbreviations.

APH:      antepartum haemorrhage.
CG154: NICE Clinical Guideline 154, December 2012. “Ectopic pregnancy and miscarriage.”
EPU:      early pregnancy unit.
GIT:       gastro-intestinal tract.
PUL:      pregnancy of unknown location.
SB:         stillbirth.
SML:      “Saving Mothers’ Lives.” March 2011. The 8th. Report of the Confidential Enquiries into Maternal Deaths in the UK.  

Suggested reading.
Obviously NICE Clinical Guideline 154!

Scenario 1.
NICE endorses the view of the authors of SML that the term “PUL” should no longer be used.
Scenario 2.
Early pregnancy is defined by in CG154 as pregnancy in the first trimester, i.e. up to 12 completed weeks.
Scenario 3.
What % of early pregnancies miscarry?
Scenario 4.
What is the rate of ectopic pregnancies per 1,000 pregnancies?
Scenario 5.
What is the mortality rate per 1,000 ectopic pregnancies?
Scenario 6
List the key things CG154 has about “support and information-giving”.
Scenario 7
Each Trust should ensure that its EPU is accessible every day.
Scenario 8
What communications training should professional staff have had?
Scenario 9
Non-clinical staff should be selected on the basis of being old, plain or, even better, ugly, so that women with pregnancy problems do not feel threatened by the presence of beautiful young women.
Scenario 10
All women with early pregnancy problems should be able to access EPUs directly and not through a health professional such as their GP.
Scenario 11
Women with miscarriage should be offered expectant management for 7 – 14 days as the first-line option.
Scenario 12
CTG 154 picks out late 1st. trimester gestation as a risk factor for bleeding.
Scenario 13
List the common clinical presentations of ectopic pregnancy that may mislead the unwary diagnostician.
Scenario 14
Surgical evacuation should be done under general anaesthesia or regional block, either epidural or spinal.
Scenario 15
Surgical treatment for ectopic pregnancy should be laparoscopic as far as possible.
Scenario 16
Salpingectomy and salpingectomy are equivalent in the management of ectopic pregnancy and should be offered according to the experience and preference of he surgeon.
Scenario 17
What proportion of women are likely to need further treatment after salpingostomy?
Scenario 18
When should women have hCG testing after salpingostomy?
Scenario 19
When should women have hCG testing after salpingectomy?
Scenario 20
When should anti-D be given and in what dose?
Scenario 21
When should a Kleihauer test be done?

Endometrial cancer.
Lead-in.
The following scenarios relate to endometrial cancer.
Pick one option from the option list.
Each option can be used once, more than once or not at all.

Option list.
Scenario 1.
A histology report on endometrial curetting is of 95% adenocarcinoma with 5% solid, non-squamous areas. What is the FIGO grade?
Scenario 2.
A histology report on endometrial curetting is of 90% adenocarcinoma with 10% solid, non-squamous areas. What is the FIGO grade?
Scenario 3.
A histology report on endometrial curetting is of 50% adenocarcinoma with 50% solid, non-squamous areas. What is the FIGO grade?
Scenario 4.
A woman undergoes surgery for carcinoma of the endometrium. Histology shows the tumour is confined to the body of the uterus with 5% myometrial invasion. What is the FIGO staging?
Answer.
Scenario 5.
A woman undergoes surgery for carcinoma of the endometrium. Histology shows the tumour is confined to the body of the uterus with 25% myometrial invasion. What is the FIGO staging?
Scenario 6.
A woman undergoes surgery for carcinoma of the endometrium. Histology shows the tumour is confined to the body of the uterus with 60% myometrial invasion. What is the FIGO staging?
Scenario 7
A woman undergoes surgery for carcinoma of the endometrium. Histology shows the tumour is confined to the uterus. There is no myometrial invasion, but there is extension to the endocervical endothelium. What is the FIGO staging?
Scenario 8
A woman undergoes surgery for carcinoma of the endometrium. Histology shows the tumour is confined to the uterus. There is no myometrial invasion, but there is extension to the stroma of the cervix. What is the FIGO staging?
Scenario 9
A woman undergoes surgery for carcinoma of the endometrium. Peritoneal washings are +ve but there is no other evidence of spread outside the uterus. There is no myometrial invasion. There is extension to the stroma of the cervix. What is the FIGO staging?
Scenario 10
A woman undergoes surgery for carcinoma of the endometrium. There is no evidence of extension outside the uterus. There is myometrial invasion through to and including the serosa. What is the FIGO staging?
Scenario 11
A woman undergoes surgery for carcinoma of the endometrium. There is myometrial invasion. Tumour is noted in the vagina. There is no evidence of disease elsewhere. What is the FIGO staging?
Scenario 12
A woman undergoes surgery for carcinoma of the endometrium. There is myometrial invasion. Tumour is noted in the vagina. Positive pelvic nodes are found, but no other lymphatic involvement. There is no distant spread. What is the FIGO staging?
Scenario 13
A woman undergoes surgery for carcinoma of the endometrium. There is myometrial invasion. Tumour is noted in the vagina. The tumour involves the mucosa of the bladder. There is no lymphatic or distant spread. What is the FIGO staging?

EMQ. Epidural anaesthesia.
Lead-in.
The following scenarios relate to epidural anaesthesia.
For each, select the answer that best fits the scenario.
Pick one option from the option list.
Each option can be used once, more than once or not at all.

Scenario 1.
Which spinal level(s) conduct pain sensation from the uterus and cervix?
Scenario 2.
Which spinal level(s) conduct pain from the perineum?
Scenario 3.
Which spinal level(s) conduct pain from the left big toe and what does it signify?
Scenario 4.
Maternal pyrexia is a complication of epidural anaesthesia.
Scenario 5.
Spinal anaesthesia is effective more rapidly than epidural anaesthesia.
Scenario 6.
Adding an opioid to the local anaesthetic drug increased the potency of epidural anaesthesia.
Scenario 7
Epidural anaesthesia increases the Caesarean section rate.
Scenario 8
Epidural anaesthesia increases the length of labour.
Scenario 9
What is the rate of incomplete block with epidural anaesthesia?

Option list.
A.        True
B.        False
C.        ≥ 1 in 10
D.        1 in 10 to 1 in 100.
E.         1 in 100 to 1 in 1,000
F.         1 in 1,000 to 1 in 50,000
G.       1 in 50,000 to 1 in 100,000
H.        1 in 100,000 or less
I.          T8 - T12
J.          T10 – L1
K.        L2 - L8.
L.         L8 - S1
M.      S1 – S4
N.       S2 – S4
O.       S3 – S5
P.        10%
Q.       20%
R.        20 – 50%
S.         50 – 70%
T.      80 – 90%
U.     90 – 100%
V.     I have no idea, I don’t care and I am going to the pub to drown my sorrows!
W.    None of the above.

Group B Streptococcus.
Lead-in.
The following scenarios relate to Group B Streptococcal disease.
Pick one option from the option list.
Each option can be used once, more than once or not at all.

Abbreviations.
Cochrane:     Cochrane Database Systematic Review 2009(3):CD007467.
EOGBS:          early-onset GBS disease.
GBS:                Group B streptococcus.
GTG:               GTG36. 2012. ”The Prevention of Early-onset Neonatal Group B Streptococcal Disease”.
 IAP:                intrapartum antibiotic prophylaxis.

Suggested reading.
Any question will be derived from the GTG, so make sure you know it well.
Option list.
  1. Streptococcus agaractiae
  2. Streptococcus intergalacticae
  3. Streptococcus agalactiae
  4. Streptococcus ubernastiae
  5. Lancelot
  6. Lanceforth
  7. Lanceford
  8. Landscape
  9. 0.01%
  10. 0.02%
  11. 0.023%
  12. 0.025%
  13. 0.05%
  14. 0.1%
  15. 0.5%
  16. 0.53%
  17. 0.54%
  18. 0.6%
  19. 0.63%
  20. 0.75%
  21. 0.9%
  22. 1%
  23. 2%
  24. 2.3%
  25. 2.4%
  26. 2.5%
  27. 5%
  28. 10%
  29. 15%
  30. 20%
  31. 25%
  32. 26.3%
  33. 21%
  34. 30%
  35. 35%
  36. 1
  37. 2
  38. 3
  39. 5
  40. 6
  41. 9
  42. 10
  43. True
  44. False
  45. you are driving me mad with all these percentages

Scenario 1.
What is the scientific name for GBS?
Scenario 2.
Which animal is the main reservoir of GBS in relation to neonatal GBS?
Scenario 2.
What system is used for grouping streptococci?
Scenario 3.
Where does GBS disease feature in the list of serious early-onset neonatal infection?
Scenario 4.
What is the upper limit in days for time of onset in the definition of “early-onset” disease?
Scenario 5.
GBS is a gram-negative, capsulated organism.
Scenario 6.
What is the incidence of EOGBS in the UK in the babies of women who have not been screened for GBS or had IAP?
Scenario 7
What is the incidence of EOGBS in the babies of American women who have had antenatal GBS screening and IAP if screen+ve?
Scenario 8
What is the mortality rate of EOGBS in the UK?



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