Website.
Contact us.
2 February 2015.
42.
|
SBA. NICE Clinical Guideline 132. Caesarean section.
|
43.
|
SBA. Pertussis
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44.
|
SBA. Kisspeptin
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45.
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EMQ. Hepatitis B.
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46.
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Viva. CNST.
|
1 Caesarean section. NICE Clinical Guideline 132.
Lead-in.
The following scenarios relate to Caesarean section.
Abbreviations.
cART: combination
anti-retroviral treatment.
CDUS: colour Doppler
ultrasound scan.
HAART: highly active
anti-retroviral therapy.
HCV: hepatitis C virus.
HSV: herpes simplex
virus.
MOD: mode of delivery.
MPA: morbid placental
adherence.
MRI: magnetic resonance
imaging.
MTCT: mother-to-child
transmission.
NVD: normal vaginal
delivery.
pCs planned Caesarean
section.
pvd planned vaginal
delivery.
PVL: plasma viral load.
SROM: spontaneous rupture of
membranes.
VBAC: vaginal birth after
Caesarean section.
Option list.
There is none, to make you think!
Scenarios.
1)
MPA is suspected on a routine 20 week scan
in a woman who has had two LSCSs. What advice should she be given in relation
to the value of colour Doppler US and MRI?
2)
What advice is
given about women who are infected with hepatitis B?
a a woman is
known to have HIV. When should a decision be taken about MOD?
b. at what
gestation should pCs be done as part of management of HIV in pregnancy?
c. at what
gestation should pCs be done in the woman with HIV, if the grounds are
obstetric or the woman’s wish, but not part of the management of HIV?
d. what advice
about MOD should be given to a woman with PVL <50 HIV RNA copies/mL at 36
weeks?
e. what advice
about MOD should be given to a woman with PVL of 200 HIV RNA copies/mL at 36
weeks?
f. what advice
about MOD should be given to a woman with PVL of 300 HIV RNA copies/mL at 36
weeks?
g. what advice
about MOD should be given to a woman with PVL of 400 HIV RNA copies/mL at 36
weeks?
h. what advice
about MOD should be given to a woman with PVL of 600 HIV RNA copies/mL at 36
weeks?
i. a woman with
HIV has been advised that normal delivery is recommended. What additional interventions
should be offered when she goes into labour?
k. what is an
elite controller?
1
|
member of the staff of Black
Rod in the House of Lords
|
2
|
crowd marshal at the Members’
Pavilion at Lord’s Cricket Ground.
|
3
|
Gentleman Usher at Buckingham
Palace party
|
4
|
one of the anti-retroviral
drugs that are essential components of HAART.
|
5
|
individual who is infected
with HIV but maintains low viral and healthy CD4 counts long-term with ART.
|
6
|
individual who is infected
with HIV but maintains low viral and healthy CD4 counts long-term without
ART.
|
l. a woman is
taking zidovudine monotherapy. Her PVL is <50 HIV RNA copies/mL at 36 weeks?
What advice would you give re MOD?
m. a woman is
taking zidovudine monotherapy. Her PVL is 200 HIV RNA copies/mL at 36 weeks?
What advice would you give re MOD?
n. a woman is
taking zidovudine monotherapy. Her PVL is 500 HIV RNA copies/mL at 36 weeks?
What advice would you give re MOD?
o. a woman is an
elite controller. What advice will you give re MOD?
3)
What advice is
given about women who are infected with hepatitis C
4)
What advice is
given about women who are infected with HIV?
5)
What advice is given about women who are
infected with HIV + hepatitis B?
6)
What advice is
given about women who are infected with HIV + hepatitis C
7)
A woman with HIV
takes HAART and has a PVL < 50 copies per ml. She wishes Caesarean section
for non-obstetric reasons. She has been counselled and Caesarean section has
been agreed. At what gestation should it be done?
8)
What advice should
be given to the woman with HSV infection in pregnancy?
9)
What is the risk
of MTCT after primary HSV infection in the 3rd. trimester?
10)
A woman presents
with genital herpes at 36 weeks’ gestation in her first pregnancy. As far as
she is aware, this is her first episode of HSV infection. What is the chance
that it is a recurrent infection?
11)
A woman presents
with genital herpes at 36 weeks’ gestation in her third pregnancy. As far as
she is aware, this is her first episode of HSV infection. What is the chance
that it is a recurrent infection?
12)
A woman presents with genital herpes at 36
weeks’ gestation in her first pregnancy. As far as she is aware, this is her
first episode of HSV infection. What test should be done to clarify whether it
is a 1ry. or recurrent infection?
13)
A woman presents with genital herpes at 36
weeks’ gestation in her first pregnancy. As far as she is aware, this is her first
episode of HSV infection. Swabs are taken from the skin lesions and blood is
taken for HSV type-specific antibodies. She goes into labour at 38 weeks before
the results of the HSV type specific antibody tests are available. What advice
should be given re mode of delivery?
14)
A woman presents
with genital herpes at 36 weeks’ gestation in her first pregnancy. As far as
she is aware, this is her first episode of HSV infection. Swabs are taken from
the skin lesions and blood is taken for HSV type-specific antibodies and
confirm 1ry. infection. She goes into labour with intact membranes at
38 weeks and declines Cs. What action should be taken with regard to anti-viral
treatment?
15)
A woman presents
in labour at 38 week’s gestation, 2 weeks after a 1ry. infection
with genital HSV. She declines Caesarean section, but opts for antiviral
treatment for her and the baby. Which drug should be considered and in what
doses?
16)
A woman presents
in labour at 38 week’s gestation, 2 weeks after a 1ry. infection
with genital HSV. She had SROM 6 hours before.
17)
A woman presents
in early labour at 38 weeks’ gestation. She has a history or recurrent genital
HSV. She has a typical herpetic blister on the vulva. What risk of neonatal
infection will you quote in the discussion?
18)
A woman presents
in labour at term with lesions and a history that are typical of 1ry.
genital HSV infection. Which invasive procedures, if any, should be avoided?
19)
A woman with a
history of recurrent genital herpes presents in labour at 40 weeks with a
typical vulval herpetic blister. Which invasive procedure, if any, should be avoided?
20)
A baby is born by
Caesarean section after maternal 1ry. genital herpes one month
before. Which, if any, of the following are appropriate?
Option
list.
A. liaise with the neonatal unit
B. normal postnatal care of the baby with examination at 24
hours, then discharge if well and feeding is established.
C. swabs of skin, conjunctiva, oropharynx and rectum for HSV
PCR
D. lumbar puncture for evidence of HSV
E. parents to be educated re good hand hygiene
F. i.v. acyclovir, 20 mg/kg 8 hourly until active infection is
ruled out.
G. strict infection control procedures should be put in place
for both mother and baby.
H. breastfeeding should be discouraged because of the presence
of HSV in breast milk.
I.
parents advised to
seek medical help if they have concerns, in particular, skin, eye or mucous
membrane lesions, lethargy, irritability or poor feeding
21)
A baby is born
normally after maternal 1ry. genital herpes one month before. The
mother had declined C section and intends to breast feed. Which, if any, of the
following are appropriate? Option list.
J.
liaise with the
neonatal unit
K.
normal postnatal care
of the baby with examination at 24 hours, then discharge if well and feeding is
established.
L.
swabs of skin,
conjunctiva, oropharynx and rectum for HSV PCR
M.
lumbar puncture for
evidence of HSV
N.
parents to be educated
re good hand hygiene
O.
i.v. acyclovir, 20
mg/kg 8 hourly until active infection is ruled out.
P.
strict infection
control procedures should be put in place for both mother and baby.
Q.
breastfeeding should
be discouraged because of the presence of HSV in breast milk.
R.
parents advised to
seek medical help if they have concerns, in particular, skin, eye or mucous
membrane lesions, lethargy, irritability or poor feeding,
S.
involvement of child
protection service.
22)
A baby is born by
Caesarean section after maternal 1ry. genital herpes one month
before. Which, if any, of the following are appropriate?
Option list.
T.
liaise with the
neonatal unit
U.
normal postnatal care
of the baby with examination at 24 hours, then discharge if well and feeding is
established.
V.
swabs of skin,
conjunctiva, oropharynx and rectum for HSV PCR
W.
lumbar puncture for
evidence of HSV
X.
parents to be educated
re good hand hygiene
Y.
i.v. acyclovir, 20
mg/kg 8 hourly until active infection is ruled out.
Z.
strict infection
control procedures should be put in place for both mother and baby.
AA.
breastfeeding should
be discouraged because of the presence of HSV in breast milk.
BB.
parents advised to
seek medical help if they have concerns, in particular, skin, eye or mucous
membrane lesions, lethargy, irritability or poor feeding
23)
What proportion of
neonatal HSV infection is thought to be due to infection after birth?
24)
What steps should
be taken to reduce the risk of neonatal HSV infection?
25)
A primigravida
attends for booking. She requests Caesarean section. There are no clinical
grounds. Outline your management.
26)
A woman with BMI
> 50 should be offered Caesarean section. True/ False.
27)
When should
prophylactic antibiotics in relation to the timing of the operation?
28)
A woman has had
her 3rd. Caesarean section. She wants to know the advice you would
give re the risks of subsequent vaginal delivery.
29) What are the key aspects of induction of general
anaesthesia for unplanned Cs?
30) What should be done about thromboprophylaxis for women
having Cs?
31) Which abdominal incision is
recommended for Cs?
A
|
William
Fletcher Shaw
|
B
|
Victor
Bonney
|
C
|
Ignaz
Semmelweis
|
D
|
Joel-Cohen
|
E
|
Pfannenstiel
|
32) Separate scalpels should be used
for the skin and subsequent incisions to reduce infection. True/False.
33) If the lower segment is
well-formed, blunt dissection should be used to extend the initial uterine
incision. True / False.
34) What is the risk of fetal
laceration?
A
|
0.1%
|
B
|
0.5%
|
C
|
1%
|
D
|
2%
|
E
|
5%
|
35) Routine use of forceps to deliver
the head is acceptable practice. True / False.
36) I.v. syntometrine is the
recommended oxytocic. True / False.
37) Which of the following statements
reflects the advice in CG132 about delivery of the placenta.
A
|
Crede’s
manoeuvre is the recommended routine method for DOP
|
B
|
Leopold’s manoeuvre is the recommended routine method
for DOP
|
C
|
Steptoe’s
manoeuvre is the recommended routine method for DOP
|
D
|
CCT
is the recommended routine method for DOP
|
E
|
MROP
manoeuvre is the recommended routine method for DOP
|
38) Co-amoxiclav is on the list of
recommended antibiotics in CG132 for routine prophylaxis at Cs. True / False.
39) Repair of the uterus is best done
with the uterus exteriorised. True / False.
40) CG132 advises that single or
double-layer closure of the lower segment are equivalent and closure is a matter
of choice for the surgeon. True / False.
41) CG132 advises closure of both
visceral and parietal peritoneum. True / False.
42) Mass closure with a
non-absorbable suture should be used for closure of mid-line incisions. True /
False.
43) What is the suggested threshold
for closure of the subcutaneous fat?
Subcutaneous
fat thickness
|
|
A
|
1
cm.
|
B
|
2
cm.
|
C
|
3
cm.
|
D
|
4
cm.
|
E
|
≥ 5
cm.
|
44) Liberal use of subcutaneous
drains is encouraged to reduce wound infection rates. True / False.
45) When choosing an antibiotic for prophylactic
use at Cs, what infections should particularly be considered?
46) Staff should be silent
immediately before and after the birth of the baby as hearing the mother’s
voice as the first ex-utero experience encourages bonding. True / False.
2. Pertussis.
Question 1.
Lead-in. Why is pertussis of current concern in obstetrics?
Option List
A.
|
Recent
research has linked pertussis in the 1st. trimester with an ↑risk
of congenital heart disease
|
B.
|
There has been a mini-epidemic of pertussis since 2011
with an increase in maternal deaths and deaths of babies < 3 months
|
C.
|
There has been a mini-epidemic of pertussis since 2011
with an increase in deaths of babies < 3 months
|
D.
|
The infecting organism causing pertussis has become
increasingly drug-resistant
|
E.
|
Pertussis in the 2nd. trimester doubles the
risk of premature delivery < 32 weeks
|
Question 2.
Lead-in
Which of
the following statements is true?
Option List
A.
|
Pertussis
is not a notifiable disease
|
B.
|
Pertussis is a notifiable disease
|
C.
|
Pertussis is not a notifiable disease, but cases should
be reported to the local bacteriologist
|
D.
|
Pertussis is not a notifiable disease, but cases should
be subject to audit
|
Question 3.
Lead-in
Which
organism causes whooping cough?
Option List
A.
|
Bordella
pertussis
|
B.
|
Bacteroides pertussis
|
C.
|
Rotavirus whoopoe
|
D.
|
Respiratory syncytiovirus pertussis
|
E.
|
None of the above
|
Question 4.
Lead-in
What is
the main reservoir of the organism that causes pertussis?
Option List
A.
|
pigs
|
B.
|
pigeons
|
C.
|
budgerigars
|
D.
|
humans
|
E.
|
none of the above
|
Question 5.
Lead-in
What is
the epidemiology of pertussis?
Option List
A.
|
the
condition is endemic
|
B.
|
the condition is endemic with mini-epidemics every 3-5
years
|
C.
|
the condition is endemic with mini-epidemics most years
in the winter months
|
D.
|
the condition is epidemic, with outbreaks at roughly
three-year intervals
|
E.
|
the condition is epidemic, with outbreaks at unpredictable
intervals
|
Question 6.
Lead-in
What
practical issues are current for obstetrician in relation to pertussis?
Option List
A.
|
The DOH
has advised that all pregnant women be immunised to reduce maternal death
rates.
|
B.
|
The DOH has advised that all pregnant women be
immunised to reduce deaths in babies < 3 months.
|
C.
|
The DOH has advised that all babies be immunised at
birth.
|
D.
|
The DOH has advised that “Boostrix- IPV” would replace “Repevax” for use in pregnancy from
July 2014.
|
E.
|
The DOH has advised that immunisation of pregnant women
be continued until 2019
|
Question 7.
Lead-in
Which, if
any, of the following statements are true in relation to pertussis vaccine.
Option List
A.
|
“Boostrix- IPV” is a vaccine for pertussis
only
|
B.
|
“Repevax” is a
vaccine for pertussis only
|
C.
|
“Boostrix- IPV”&
“Repevax” are live, attenuated vaccines
|
D.
|
“Boostrix- IPV”
& “Repevax” are vaccines against diphtheria, tetanus and polio as well as
pertussis
|
E.
|
“Boostrix-
IPV” & “Repevax” are acellular
|
3. Kisspeptin.
In relation to kisspeptin, pick the best answer from the
list below.
A.
|
is a pheromone released by the hypothalamus during
passionate embraces
|
B.
|
is a digestive enzyme released by the salivary glands
during passionate embraces
|
C.
|
is a digestive enzyme found in human carnivores but not
vegetarians
|
D.
|
does not exist
|
E.
|
is thought necessary for trophoblastic invasion and low
levels have been linked to miscarriage and recurrent miscarriage
|
4. Hepatitis B and pregnancy.
Lead-in.
Each of the following scenarios relates to
hepatitis B and pregnancy.
Instructions.
For each scenario, select the most appropriate
option from the option list.
Each option can be used once, more than once or
not at all.
Abbreviations.
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
Option list.
A.
acyclovir
B.
divorce
C.
HBcAg +ve
D.
HBeAg +ve
E.
HbsAg +ve
F.
HBsAg +ve; HBsAb –ve; HBcAb -ve
G.
HBsAg +ve; HBsAb –ve on two tests six
months apart
H.
HBsAG –ve; HBsAb -ve on two tests six
months apart
I.
HBsAg –ve; HBsAb +ve; HBcAb –ve
J.
HBsAg –ve; HBsAb +ve; HBcAb +ve
K.
HBsAg –ve; HBsAb +ve
L.
HBsAg +ve; HBcAg +ve
M.
HBV vaccine.
N.
HBIG
O.
HBV vaccine + HBIG
P.
immune as a result of infection
Q.
immune as a result of vaccination
R.
not immune
S.
chronic carrier of HBV infection
T.
10%
U.
30%
V.
50%
W.
60%
X.
70 - 90%
Y.
soap and boiling water
Z.
10% dilution of bleach in water
AA. 10%
dilution of formaldehyde in alcohol
BB. ultraviolet
irradiation
CC. yes
DD.no
EE. none
of the above
Scenario 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 infection?
Scenario 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 natural infection?
Scenario 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?
Scenario 4.
An asymptomatic primigravida books at
10 weeks. Her partner had an acute HBV infection 6 months ago. What results on
routine blood testing would indicate that she is a chronic carrier of HBV
infection?
Scenario 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?
Scenario 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?
Scenario 7
A primigravid woman at 8 weeks
gestation is found to be non-immune to the HBV. She has recently married and
her husband is a chronic carrier. What should be done to protect her from
infection?
Scenario 8
A woman is a known carrier of
Hepatitis B. What is the risk of vertical transmission in the first trimester?
Scenario 9
A woman is a known carrier of
Hepatitis B. What is the risk of the neonate who has been infected by vertical
transmission in the third trimester becoming a carrier without treatment?
Scenario 10
How effective is hepatitis B
prophylaxis in preventing chronic carrier status developing in a neonate
infected as a result of vertical transmission?
Scenario 11
Can a woman who is a chronic HBV
carrier breastfeed safely?
Scenario 12.
Hepatitis B infection is the most dangerous of
the viral hepatitis infections in pregnancy.
Scenario 13.
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?
Scenario 14.
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?
Scenario 15.
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! Yes / No.
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