Monday 17 August 2015

Tutorial 17th. August 2015

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17 August 2015.

38
EMQ. Severe PET
39
EMQ. Surrogacy
40
EMQ. Germ cell tumours
41
SBA. Androgen insensitivity syndrome
42
EMQ. Vulval conditions


38. EMQ. Severe PET.
Scenario.
A woman is admitted to the delivery unit at 32 weeks’ gestation with BP 190/130, proteinuria +++ and 4 beats of clonus.
It is decided that she has severe PET and will probably need to be delivered in the next few days.
The local protocol for the management of severe PET mentions the following possible treatments.
Which should be administered first?
Treatments.
A.       
betamethasone 12 mg. i.m. with repeat dose after 24 hours
B.       
crystalloid fluid 500 ml. i.v.
C.       
diazepam i.v.
D.       
diazepam oral
E.        
labetalol i.v.
F.        
labetalol oral
G.       
low molecular weight heparin
H.       
magnesium sulphate i.v.
I.         
nifedipine oral


39. EMQ. Surrogacy.
Surrogacy.
Abbreviations.
ART:           assisted reproductive technology
CF:              commissioning father
CM:            commissioning mother
CPs:            commissioning parents
PO:             parental order
SM:             surrogate mother
Option List.
a)      CM
b)      CF
c)       CPs
d)      SM
e)      Chairman of the HFEA
f)        Senior judge at the Children and Family Court
g)       traditional surrogacy
h)      gestational surrogacy
i)        HFEA
j)        SSAEW
k)       RCOG Surrogacy Sub-Committee
l)        false
m)    true
n)      none of the above

Scenario 1
List the different types of surrogacy.
Scenario 2.
“Gestational” surrogacy has better “take-home-baby” rates than “traditional” surrogacy.
Scenario 3.
There are approximately 1,000 surrogate pregnancies per annum in the UK. True/False
Scenario 4.
Which national body regulates surrogacy in England?
Scenario 5.
Privately-arranged surrogate pregnancies are illegal and those involved are liable to up to 2 years in prison. True/False
Scenario 6.
List the risks of surrogacy.
Scenario 7.
Obstetricians are legally obliged to take the CPs’ wishes into consideration in managing pregnancy complications or problems.
Scenario 8.
The psychological outcomes of surrogacy are fully understood. True/False.
Scenario 9.
The psychological outcomes of surrogacy are more severe after traditional surrogacy. True/False
Scenario 10.
Who has the right to arrange TOP if the fetus is found to have a major congenital abnormality?
Scenario 11.
A SM decides at 10 weeks that she does not wish to be pregnant and arranges to have a TOP. The CPs. hear about this and object strongly. To whom should they apply to have the TOP blocked?
Scenario 12.
A woman has hysterectomy and BSO to deal with extensive endometriosis at the age of 30. She marries two years later and her sister offers to act as surrogate. She undergoes IVF and 4 embryos are created. One is transferred and a successful pregnancy ensues. The baby is adopted by the woman and her husband. The 3 remaining embryos were frozen. Four years later the woman falls out with her sister, but finds another surrogate and wishes to proceed with another pregnancy. The sister says she does not want her eggs to be used and that the frozen embryos should not be transferred. Does the sister have the legal right to block the use of the embryos? Yes / No.
Scenario 13.
A girl born from donor sperm reaches the age of 16 and wishes to know the identity of her genetic father. Does she have the right to this information?  Yes / No.
Scenario 14.
A girl born from donor sperm reaches the age of 18 and wins a place at Oxford University to read medicine. Does she have the legal right to get the donor to contribute to her fees? Yes / No.
Scenario 15.
A PO is active from the moment it is completed and signed by the relevant parties.  True/False
Scenario 16.
A SM can change her mind at any time and keep the child, even if the egg was not hers.  True/False
Scenario 17.
The CPs can change their mind, leaving the SM as the legal mother.  True/False
Scenario 18.
A SM’s husband is the legal father until adoption is completed or a PO comes into force.


Scenario 19.
A lesbian couple is a stable, co-habiting relationship can be CPs and become the legal parents of the child of a SM.
Scenario 20.
CPs are likely to get faster legal status as the legal parents through application for a PO rather than applying for adoption.

40. EMQ. Germ cell and sex cord tumours and substances secreted.
Lead-in.
The following scenarios relate to the substances that ovarian cell tumours usually secrete.
For each, select the most appropriate substance from the option list.
Each option can be used once, more than once or not at all.
Option List.
A.       
a-fetoprotein.
B.       
a-fetoprotein + hCG.
C.       
a1-antitrypsin
D.       
Androgen.
E.        
Ascites.
F.        
Walthard
G.       
Ca125
H.       
hCG.
I.         
β-hCG
J.         
Follicle stimulating hormone.
K.        
Luteinising hormone.
L.        
Oestrogen.
M.     
Prolactin.
N.       
Thyroxine sufficient to produce hyperthyroidism.
O.      
Pleuritic fluid.
P.        
None of the above.

Scenario 1.
Mature cystic teratoma.
Scenario 2.
Granulosa cell tumour.
Scenario 3.
Sertoli-Leydig tumours.
Scenario 4 .
Brenner tumour.
Scenario 5.
Struma ovarii.
Scenario 6.
Embryonal carcinoma.
Scenario 7.
Polyembryoma.
Scenario 8.
Endodermal sinus tumour (Yolk sac tumour).
Scenario 9.
Dysgerminoma.
Scenario 10.
Primary ovarian choriocarcinomas.

41. EMQ. Topic. Androgen insensitivity syndrome.

Abbreviations.
AIS:             androgen insensitivity syndrome

Question 1.
Lead-in
What is the estimated prevalence of AIS?
Option List
A.       
2-5 per 100,000 boys at birth
B.       
5-10 per 100,000 girls at birth
C.       
2-5 per 100,000 genetic males at birth
D.       
5-10 per 100,000 genetic females at birth
E.        
none of the above.

Question 2.
Lead-in
Which of the following sub-types of AIS do not exist?
Sub-types
1.        
complete AIS
2.        
incomplete AIS
3.        
mild AIS
4.        
partial AIS
5.        
total AIS
Option List
A.       
1
B.       
2
C.       
3
D.       
4
E.        
5
F.        
1 + 3
G.       
2 + 3
H.       
2 + 5
I.         
3 + 5
J.         
4 + 5

Question 3.
Lead-in
How common is partial AIS?
Option List
A.       
at least as common as complete AIS
B.       
at least as common as total AIS
C.       
less common than mild AIS
D.       
as common as incomplete AIS
E.        
none of the above.

Question 4.
Lead-in
How common is incomplete AIS?
Option List
A.       
at least as common as complete AIS
B.       
at least as common as total AIS
C.       
less common than mild AIS
D.       
as common as partial AIS
E.        
none of the above.

Question 5.
Lead-in
How common is mild AIS?
Option List
A.       
at least as common as complete AIS
B.       
at least as common as total AIS
C.       
less common than complete AIS
D.       
as common as partial AIS
E.        
none of the above.

Question 6.
Lead-in
No more prevalence!!
What is the mode of inheritance of AIS?
Option List
A.       
autosomal dominant
B.       
autosomal recessive
C.       
X-linked dominant
D.       
X-linked recessive
E.        
mitochondrial

Question 7.
Lead-in
What proportion of AIS is due to new mutations?

Option List

A.       
0%
B.       
1 – 20%
C.       
21 – 40%
D.       
41-60%
E.        
61-80%

Question 8.
Lead-in
Which gene is involved in AIS?

Option List
A.       
androgen receptor gene
B.       
aromatase receptor gene
C.       
androstenedione gene
D.       
oestrogen receptor gene
E.        
none of the above

Question 9.
Lead-in
How many mutations have been described of the gene which is involved in AIS?

Option List

A.       
0-10
B.       
11-100
C.       
101-200
D.       
201-300
E.        
>300

Question 10.
Lead-in
Which is the most common clinical presentation in AIS?
Option List
A.       
ambiguous genitalia
B.       
precocious puberty
C.       
premature menopause
D.       
primary amenorrhoea
E.        
secondary amenorrhoea

Question 11.
Lead-in
Which of the following are more common in AIS?
Option List

A.       
anlagen
B.       
coarctation of the aorta
C.       
“coast of Maine” pigmentation pattern
D.       
renal tract anomalies
E.        
none of the above.

Question 12.
Lead-in
A woman of 20 is found to have AIS. She has a pre-pubertal sister. What is the chance that the sister also has AIS, assuming that the condition is not due to a new mutation in the elder sister?
Option List
A.       
1 in 1
B.       
1 in 2
C.       
1 in 4
D.       
1 in 8
E.        
1 in 16

Question 13.
Lead-in
What is the risk of the gonads becoming malignant in AIS?
Option List
A.       
10%
B.       
20%
C.       
30%
D.       
> 30%
E.        
accurate risk not known

42. EMQ. Vulval conditions.
Lead-in.
The following scenarios relate to vulval conditions.
Choose the most likely vulval condition from the option list.
Each option can be used once, more than once or not at all.
Option list.
A.
Acne.
B.
Behçet’s syndrome.
C.
Candidiasis.
D.
CIN 3
E.
CIN1
F.
Crohn’s disease.
G.
Dermatitis.
H.
Eczema.
I.
Genital warts.
J.
Hidradenitis suppurativa.
K.
Leprosy.
L.
Lichen planus
M.
Lichen sclerosis
N.
Lymphogranuloma venereum
O.
Normal skin.
P.
Psoriasis.
Q.
Seborrhoeic dermatitis.
R.
Type 1 diabetes mellitus
S.
Type 2 diabetes mellitus
T.
Ulcerative colitis.
U.
VIN III.

Scenario 1.
A 22 year-old woman attends the colposcopy clinic after 2 smears showing minor atypia. The cervical appearances are of aceto-white with punctation. 
Scenario 2.
A 60-year old woman has an erythematous rash of the vulva extending to the inner thighs. A similar rash is noted under the breasts. She is not known to have diabetes.
Scenario 3.
A woman attends the gynaecology clinic with a vulval rash. It has a “lacy” appearance.  
Scenario 4.
A 35-year old woman attends is noted to have a vulval fistula. She has a history of episodic diarrhoea. 
Scenario 5.
A 25-year old woman attends the gynaecology clinic with a history of intense vulval itching and soreness. The appearances are of diffuse erythema with excoriation. Diabetes, candidiasis and other local infections have been eliminated by the GP. 
Scenario 6.
A 35-year old woman attends the gynaecology clinic with vulvitis. She also has a scalp rash. Clinical examination shows scaly, pink patches with signs of excoriation. Skin samples grow Malassezia ovalis.
Scenario 7.
A 40-year old woman has evidence of chronic vulval ulceration. She has recently been seen by a dermatologist for mouth ulceration and has been started on thalidomide.
Scenario 8.
An African woman of 35 years attends the gynaecology clinic. She has a ten-year history of chronic vulval ulceration. Examination shows multiple, tender vulval and pubic subcutaneous nodules, some of which have ulcerated.
Scenario 9.
A Caucasian woman of 29 years attends the gynaecology clinic with a chronic vulval rash. Examination shows erythematous areas with clearly defined margins and white scaly patches. 
Scenario 10.
A 30-year old woman attends the gynaecology clinic with vulval itching. Examination shows erythema of the labia minora and perineum. Full-thickness biopsy shows abnormal cell maturation throughout the epithelium with increased mitotic activity.
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