Thursday, 6 August 2015

Tutorial 6 August 2015

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6 August 2015.

28
SBA. Recurrent miscarriage
29
EMQ. Obstetric cholestasis 1
30
EMQ. Obstetric cholestasis 2
31
EMQ. Myocardial infarction.
32
EMQ. APH.

28. Recurrent miscarriage
This question and answer are derived from a question written by Selvambigai Raman.
Abbreviations.
EPAS:            early pregnancy assessment service.
EPU:              dedicated early pregnancy assessment unit.
GDG:             guideline development group.
GGT:              Gamma-glutamyl transferase.
GTD:              gestational trophoblastic disease.
NK:                natural killer.
PCOS:            polycystic ovary syndrome.
PIGD:            pre-implantation genetic diagnosis.
PIGS:             pre-implantation genetic screening.
RM:               recurrent miscarriage.
TORCH:         Toxoplasmosis, rubella, cytomegalovirus & herpes. (Other definitions include HIV, syphilis and other infections.) Fortunately, TORCH screening is out-of-date, exact definitions are not important, though I’d stick with the first if asked.
UA:                uterine anomaly.

Question 1.
Lead-in
In relation to miscarriage, which, if any, of the following statements are correct?
  1. the term “spontaneous miscarriage” is really stupid
  2. most miscarriages are genetic in causation.
  3. most women who miscarry do not get a diagnosis of causation
  4. the majority of women have significant levels of psychological distress after miscarriage.
  5. counselling is of significant benefit in reducing levels of psychological distress after miscarriage.

Option List
A.       
i + ii
B.       
i + ii + iii
C.       
i + ii + iii + iv
D.       
i + ii + iii + v
E.        
i + ii + iii + iv + v

Question 2.
Lead-in
Which of the following statements are true.
  1. miscarriage occurs in 11% of women with age 20-24 years
  2. miscarriage occurs in 25% of women with age 35-39 years
  3. miscarriage occurs in > 90% of mothers with age ≥ 45 years
  4. recurrent miscarriage affects about 1% of couples
  5. recurrent miscarriage affects about 5% of couples
Option List
A.       
i + ii
B.       
i + iii
C.       
i + ii + iv
D.       
i + iii + v
E.        
i + ii + iii + iv

Question 3.
Lead-in
What figure is usually given for the overall incidence of miscarriage?
Option List
A.       
< 10 %
B.       
10 - 20%
C.       
20 - 25%
D.       
25 – 30 %
E.        
>30%

Question 4.
Lead-in
A healthy, 26-year-old, woman attends the booking clinic at 6 weeks in her first pregnancy. A pregnancy test is +ve. Her best friend recently had an early miscarriage. What risk will you quote?
Option List
A.       
≤ 5%
B.       
5 – 10%
C.       
10 – 15%
D.       
15 – 20%
E.        
≥ 20%

Question 5.
Lead-in
The same healthy woman attends the ANC at 8 weeks for a dating scan. Before she has the scan she asks you what her risk is now. She has had no abnormal symptoms. What risk will you quote?
Option List
A.       
≤ 5%
B.       
5 – 10%
C.       
10 – 15%
D.       
15 – 20%
E.        
≥ 20%

Question 6.
Lead-in
The same healthy, nulliparous woman comes back to see you after the scan. The scan is normal and shows a viable fetus. She asks what her risk is now. What risk will you quote?
Option List
  1.  
≤ 5%
  1.  
5 – 10%
  1.  
10 – 15%
  1.  
15 – 20%
  1.  
≥ 20%

Question 7.
Lead-in
Pick the best option from the list below for the definition of RM.
Option List
  1.  
two or more miscarriages
B.
two or more miscarriages in healthy women
C.
three or more miscarriages
D.
three or more miscarriages in women with no children
E.
none of the above.

Question 8.
Lead-in
The following are possible causes of RM except for one. Pick the best option for the exception.
Option List
  1.  
increased maternal age
  1.  
maternal cigarette smoking
  1.  
maternal alcohol consumption
  1.  
exposure to anaesthetic gases
  1.  
exposure to emissions from video display terminals

Question 9.
Lead-in
A woman presents to antenatal clinic for booking at 6 weeks. She has a history of 3 RMs with no explanation found after full investigation. What is her risk of miscarriage in this pregnancy?
Option List
A.       
≤ 10%
B.       
   20%
C.       
   25%
D.       
   50%
E.        
   75%

Question 10.
Lead-in
4) A 35-year-old woman with a history of 3 RMs presents to you for advice regarding the risk of miscarriage if she conceives. Pick the best option to describe her risk from the list below.
Option List
A.       
20%
B.       
30%
C.       
40%
D.       
50%
E.        
55%

Question11.
Lead-in
The following statement relates to women with arcuate uteri.
There is evidence to suggest that women with arcuate uteri:
                i.     tend to miscarry more in first trimester
              ii.     tend to miscarry more in second trimester
            iii.     have no increased risk of miscarriage
            iv.     are at increased risk of cephalo-pelvic disproportion
              v.     are at increased risk of Caesarean section
Pick the best option from the list below.
Option List
A.       
i
B.       
i + v
C.       
ii + iv
D.       
ii + v
E.        
iii + v

Question 12.
Lead-in
With regards to EPUs, which of the following statements, if any, are true.
         i.            all women with pain + bleeding in early pregnancy can self-refer to an EPU
       ii.            all women with pain + bleeding in early pregnancy should be seen by a health professional before referral to an EPU
     iii.            women with a history of ectopic pregnancy, molar pregnancy or recurrent miscarriage should be able to self-refer to an EPU
     iv.            women with a history of puerperal psychosis should be able to self-refer to an EPU
Option List
A.       
i
B.       
ii
C.       
iii
D.       
iv
E.        
iii + iv

Question 13.
Lead-in
Which, if any, of the following investigations should be done for a couple with 1st trimester RM?
         i.            APS screen
       ii.            Fragile X syndrome screen
     iii.            HbA1c
     iv.            hysterosalpingogram
       v.            inherited thrombophilia screen
     vi.            karyotyping
    vii.            NK cells in peripheral blood
  viii.            thyroid function tests
     ix.            TORCH screen
Option List
A.       
i
B.       
i +  v
C.       
i + ii + v + vi + viii + ix
D.       
i + iii + iv + v + vi + vii + viii + ix
E.        
all of the above except vii

Question 14.
Lead-in
Which, if any of the following treatments should be offered to women with RM and evidence of APS?
Option List
         i.             
low-dose aspirin + clopidogrel
       ii.             
low-dose aspirin + LMWH
     iii.             
low-dose aspirin + LMWH + low-dose corticosteroids
     iv.             
low-dose aspirin + unfractionated heparin
       v.             
low-dose aspirin  + unfractionated heparin + low-dose corticosteroids

Question 15.
Lead-in
Which, if any, of the following treatments are of proven benefit in improving outcomes in unexplained RM?
         i.            cervical cerclage
       ii.            hCG
     iii.            leptin
     iv.            LH
       v.            metformin
     vi.            rectal or vaginal progesterone
    vii.            supportive therapy in a dedicated EPU
  viii.            PIGS
Option List
A.       
i + ii
B.       
i + vi + vii
C.       
ii + vi + vii + vii
D.       
 vii
E.        
none of the above

Question 16 .
Lead-in
With regard to the role of PIGS in the management of women with unexplained RM, which, if any, of the following statements are true.
         i.            PIGS is of proven benefit in unexplained RM
       ii.            PIGS is regulated by the HFEA
     iii.            PIGD and PIGS are different names for the same process
Option List
A.       
i
B.       
ii
C.       
i + ii
D.       
i + ii + iii
E.        
none of the above

Question 17.
Lead-in
Pick the most appropriate option from the list below about the risk of miscarriage in women with PCOS and a history of RM who conceive spontaneously.
Option List
A.       
increased serum LH levels predict an increased risk of miscarriage
B.       
Increased testosterone levels predict an increased risk of miscarriage
C.       
Decreased androgen levels predict an increased risk of miscarriage
D.       
Typical PCOS ovarian morphology predicts an increased risk of miscarriage
E.        
Hyperinsulinaemia predicts an increased risk of miscarriage


29. Obstetric cholestasis. (OC). 1. Prevalence.
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?

30. Obstetric cholestasis. (OC) 2.
Lead-in.
The following scenarios relate to the definition, diagnosis and management.
Pick one option from the option list.
Each option can be used once, more than once or not at all.
Abbreviations.
gamma GT: gamma-glutamyl transferase
GTG:     RCOG’s Green-top Guideline No. 43. April 2011.
OC:        obstetric cholestasis.
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.

31. Topic. Myocardial infarction 1.
Lead in.
Myocardial infarction will definitely be in the exam database. It is mentioned in recent maternal mortality reports and there was a TOG article in 2013.

Abbreviations.
ACS:                 acute coronary syndrome
CAD:                 coronary artery disease
DTA:                 dissection of thoracic aorta
IHD:                  ischaemic heart disease
LADCA:            left, anterior, descending coronary artery.
MBRRACE:      MBRRACE-UK: Mothers and Babies: Reducing Risk through Audits and Confidential Enquiries in the UK
MBRRACE14:  MBRRACE 1st. Report. Saving Lives, Improving Mothers’ Care Lessons learned to inform future maternity care from the UK and Ireland Confidential Enquiries into Maternal Deaths and Morbidity 2009-012. Published December 2014
MI:                   myocardial infarction
MMRpt:           Maternal Mortality Report 2006-8: “Saving Mothers’ Lives. Reviewing maternal deaths to make motherhood safer: 2006-2008
UKOSS:            UK Obstetric Surveillance System
VH:                   ventricular hypertrophy
                            
Question 1.
Lead-in
Where did cardiac disease rank in the direct and indirect causes of maternal death for the years 2010-12 in MBRRACE14?
Option List
F.        
1
G.       
2
H.       
3
I.         
4
J.         
5

Question 2.
Lead-in
What has happened to the incidence of maternal death due to cardiac disease in the UK since 1985?
Option List

A.       
it has roughly increased by a factor of 1.5
B.       
it has roughly increased by a factor of 2.3
C.       
it has roughly increased by a factor of 3.0
D.       
it has roughly reduced by a quarter
E.        
it has roughly reduced by a half

Question 3.
Lead-in
What was the estimated prevalence of MI in the UKOSS survey?
There is no option list – what is your figure?

Question 4.
Lead-in
What risk factors for MI were identified in the UKOSS survey?

Question 5.
Lead-in
What underlying pathological conditions were noted in the UKOSS survey of MI?
             
Question 6.
Lead-in
What risk factors for MI have been mentioned in recent Maternal Mortality Reports?
There is no option list.
Write your list and you can compare it with the list in the answers.
             
Question 7.
Lead in
What risk factors for MI have been reported in other publications?
A big question!! Write your list and compare it with mine.

Question 8.
Lead-in
How are the causes of MI normally categorised and what are the sub-headings in the main categories.
You know this or could work it out, certainly the main headings and most of the sub-headings.
Write your list and you can compare it with the answer.

Question 9.
Lead-in
What ECG criteria are used to categorise acute myocardial infarction?
Option List
A.       
presence of arrhythmia
B.       
presence of QT interval prolongation
C.       
presence of ST segment depression
D.       
presence of ST segment elevation
E.        
presence of T wave inversion

Question 10.
Lead-in
What ECHO criteria are used to categorise acute myocardial infarction?
Option List
A.       
presence of arrhythmia
B.       
presence of atrial dilatation
C.       
presence of ventricular dilatation
D.       
presence of mitral valve reflux
E.        
none of the above

Question 11.
Lead-in
With regard to coronary artery dissection, which of the following statements are false?
Statements.
A.       
only occurs in women with coronary artery disease
B.       
mainly occurs in the right anterior descending branch of the coronary artery
C.       
is most common in the puerperium
D.       
is particularly associated with the use of ergometrine for management of the 3rd. stage and its complications
E.        
is associated with mortality rates ≥ 50%, mainly due to late diagnosis or mis-diagnosis

Option List

1.        
A + B + C
2.        
A + C + D
3.        
B + D
4.        
B + D + E
5.        
A + B + C + D + E

Question 12.
Lead-in
Which ECG feature is particularly used to diagnose MI?
Option List
A.       
presence of arrhythmia
B.       
presence of QT interval prolongation
C.       
presence of ST segment depression
D.       
presence of ST segment elevation
E.        
presence of T wave inversion

Question 13.
Lead-in
Which blood markers are best for the diagnosis of MI?
Markers
1.        
Treponemin A
2.        
Treponemin B
3.        
Troponin A
4.        
Troponin I
5.        
Troponin T

Option List
A
1 + 2
B
3
C
3 + 4
D
3 + 5
E
4 + 5
F
none of the above

Question 14.
Lead-in
Which of the following statements are true about the blood markers that are best for the diagnosis of MI?
Statements
1.        
Their levels are normal in normal pregnancy
2.        
Their levels are increased from about 28 weeks, making pregnancy-specific ranges mandatory
3.        
Their levels rise with prolonged labour
4.        
Their levels rise with Caesarean section
5.        
Their levels can be elevated in pregnancy-induced hypertension and PET
6.        
Their levels can be elevated in pulmonary embolism

Option List
A
1 + 3
B
1 + 3 + 4
C
2 + 3 + 4
D
1 + 3 + 5
E
1 + 5 + 6
F
none of the above

Question 15
Lead-in
How many maternal deaths due to cardiac disease were reported for the years 2010-12 in MBRRACE14?

Option List

A.       
10
B.       
26
C.       
38
D.       
47
E.        
54

Question 16.
What were the main causes of maternal death from cardiac disease in 2010-12?
List of possible causes.
F.        
aortic dissection
G.       
atherosclerosis
H.       
atrial fibrillation
I.         
coronary thrombosis
J.         
myocardial infarction
K.        
peripartum cardiomyopathy
L.        
sudden adult death syndrome
M.     
ventricular fibrillation

Option List

A.       
A + B + C + D + E + F + G + H
B.       
A + B + C + D + E + F + G + H
C.       
A + B + C + D + E + F + G + H
D.       
A + B + C + D + E + F + G + H
E.        
A + B + C + D + E + F + G + H

Question 17.
How many maternal deaths were attributed to myocardial infarction in MBRRACE14?

Option List

A.       
  0
B.       
  5
C.       
  8
D.       
12
E.        
36

Question 18.
Lead-in
What are the latest figures for the split between congenital and acquired disease in deaths due to cardiac disease and what years do they derive from?

Option Lists
    List 1                                               List 2
A
  3: 100

F
2006-08
B
  6: 100

G
2007-09
C
13: 100

H
2008-10
D
31: 100

I
2009-11
E
50: 100

J
2010-12

Question 19.
Lead-in
Question 6.
Lead-in
Which causes of death have occupied the number 1 spot in the ranking order of the causes of direct and indirect maternal deaths in the past 30 years?
List of causes.
1.        
AFE
2.        
anaesthesia
3.        
early pregnancy: ectopic, miscarriage & TOP
4.        
cardiac disease
5.        
haemorrhage
6.        
PET, eclampsia, pregnancy-induced hypertension
7.        
psychiatric disease including suicide
8.        
sepsis
9.        
thromboembolism/ thrombosis

Option List

F.        
4 + 5
G.       
4 + 9
H.       
4 + 5 + 6 + 8
I.         
4 + 5 + 6 + 7 + 8
J.         
all of the above

32. Antepartum haemorrhage.
Lead-in.
The following scenarios relate to APH.
Pick one option from the option list.
Each option can be used once, more than once or not at all.

Abbreviations.
ART:      assisted reproduction technology
FGR:      fetal growth restriction
GTG:     Green-top guideline no 62
PET:      pre-eclampsia

Option list.
A.        genital tract bleeding ≥ 500 ml. from 24 weeks until the delivery of the baby
B.         genital tract bleeding ≥ 500 ml. from 24 weeks until the delivery of the placenta.
C.         genital tract bleeding ≥ 500 ml. from 24 weeks, or earlier if the baby is live-born, until the delivery of the baby.
D.        1
E.         2
F.         3
G.        4
H.        5
I.           6
J.          7
K.         8
L.          9
M.      10
N.        15
O.        20
P.         30
Q.        50
R.         100
S.         500
T.         1,000
U.        true
V.        false
W.      none of the above
Scenario 1.
What is the definition of APH?
Scenario 2.
What is the upper limit in ml. for minor APH
Scenario 3.
What is the upper limit in ml. of major haemorrhage
Scenario 4.
What is the % risk of recurrence after 1 abruption?
Scenario 5.
What is the % risk of recurrence after 2 abruptions?
Scenario 6.
What is the major risk factor for placental abruption.
Scenario 7
List 10 risk factors for placental abruption.
Scenario 8
List 6 risk factors for placenta previa.
Scenario 9
In what % of pregnancies does APH occur?
Scenario 10
With regards to steps that can be taken to reduce the incidence of APH, what things would you include in an essay?





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1 comment:

  1. Unknown14 October 2015 at 00:59

    Dear dr.tom
    Would u please post the answer sheets.
    Regards
    Zainab

    ReplyDelete

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