21st. December 2015.
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31
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SBA. Ovarian reserve.
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32
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EMQ. Anti-D.
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33
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EMQ.
Headache.
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34
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EMQ. Obstetric cholestasis. Prevalence
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35
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EMQ. Obstetric cholestasis. Diagnosis &
management
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36
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Communication skills
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31. SBA.
Ovarian reserve.
Abbreviations.
AFC: antral
follicle count
AMH: anti-Müllerian
hormone.
OR: ovarian
reserve.
Question 1.
Lead-in
What is
the definition of ovarian reserve?
Option List
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A.
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Sex-hormone-induced
female shyness.
|
|
B.
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the number of functional oocytes per cubic centimetre
of ovarian tissue
|
|
C.
|
the number of oocytes per cubic centimetre of ovarian
tissue
|
|
D.
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the number of remaining oocytes
|
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E.
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the proportion of residual to primordial oocytes
|
Question 2.
Lead-in
What is
the definition of the menopause?
Option List
|
A.
|
the end
of menstruation
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B.
|
the end of menstruation, but not if hysterectomy is the
cause
|
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C.
|
the end of menstruation, but not if endometrial
ablation is the cause
|
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D.
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the time when periods become infrequent and finally cease
|
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E.
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the climacteric
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Question 3.
Lead-in
How many
periods must be missed for the menopause to be diagnosed?
Option List
|
A.
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6
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B.
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9
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C.
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12
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D.
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24
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E.
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none of the above
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Question 4.
Lead-in
What is
the definition of the climacteric?
Option List
|
A.
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the same
as “menopause”
|
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B.
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the same as the “perimenopause”
|
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C.
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the time from the start to the end of vasomotor
symptoms
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D.
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the time from the start of menopausal symptoms to one
year after the LMP
|
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E.
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I am never going to use this term again, so don’t ask
me about it!
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F.
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none of the above
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Question 5.
Lead-in
What is
the definition of premature menopause?
Option List
|
A.
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menopause
occurring at an earlier age in successive generations
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B.
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menopause occurring < 50 years
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C.
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menopause occurring < 45 years
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D.
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menopause occurring < 40 years
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E.
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menopause occurring < 35 years
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Question 6.
Lead-in
Which of
the following conditions is not associated with premature menopause.
Conditions.
|
1.
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45XO/XX mosaicism
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2.
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Fragile
X pre-mutation carrier status
|
|
3.
|
Fragile X full mutation carrier status
|
|
4.
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galactosaemia
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5.
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Mayer – Rokitansky – Kuster - Hauser syndrome
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6.
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Swyer’s syndrome.
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Option List
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A.
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1 + 2 + 4
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B.
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1 + 2
+ 4 + 5
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C.
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1 + 2 + 4 + 6
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D.
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1 + 3 + 4
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E.
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3 + 4 + 5
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F.
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3 + 5 + 6
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G.
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all of the conditions
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H.
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some of the conditions, but I don’t know which
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I.
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none of the conditions
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Question 7.
Lead-in
A woman is
a carrier of the Fragile X pre-mutation. What is her risk of premature ovarian
failure?
Option List
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A.
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5%
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B.
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10%
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C.
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15%
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D.
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20%
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E.
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25%
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Question 8.
Lead-in
Where is
FSH produced?
Option List
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A.
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granulosa cells
|
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B.
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hypothalamus
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C.
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pineal gland
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D.
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anterior
pituitary
|
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E.
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posterior pituitary
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Question 9.
Lead-in
Where is
LH produced?
Option List
|
A.
|
granulosa cells
|
|
B.
|
hypothalamus
|
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C.
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pineal gland
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|
D.
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anterior
pituitary
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|
E.
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posterior pituitary
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Question 10.
Lead-in
Where is
Inhibin A produced?
Option List
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A.
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granulosa
cells
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|
B.
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granulosa cells of small developing follicles
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C.
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granulosa cells of the dominant follicle and corpus
luteum
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D.
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ovarian stroma
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E.
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adrenal gland
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Question 11.
Lead-in
Where is
Inhibin B produced?
Option List
|
A.
|
granulosa
cells
|
|
B.
|
granulosa cells of small developing follicles
|
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C.
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granulosa cells of the dominant follicle and corpus
luteum
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D.
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ovarian stroma
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E.
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adrenal gland
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Question 12.
Lead-in
Where is
AMH produced?
Option List
|
A.
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granulosa
cells
|
|
B.
|
granulosa cells of small antral follicles
|
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C.
|
granulosa cells of the pre-antral follicles
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D.
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dominant follicle and corpus luteum
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E.
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ovarian stroma
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Question 13.
Lead-in
Which if
any of the following statements are true?
Statements.
|
1.
|
AFC is
based on antral follicles up to 2 mm in diameter
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2.
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AFC is based on antral follicles up to 5 mm in diameter
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3.
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AFC is based on antral follicles up to 10 mm in
diameter
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4.
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AFC is of proven superiority to AMH assay in assessing
OR
|
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5.
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AFC + AMH assay is a superior test to AMH assay alone
in assessing OR
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Option List
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A.
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1 + 5
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B.
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2 + 5
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C.
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3 + 5
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D.
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4
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E.
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4 + 5
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F.
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none of the above
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Question 14.
Lead-in
Which is
the best test to measure ovarian reserve?
Option List
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A.
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early
follicular FSH levels
|
|
B.
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luteal follicular FSH levels
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C.
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early follicular-phase FSH + LH levels
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D.
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early follicular-phase AMH levels
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E.
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early follicular-phase AFC
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F.
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none of the above
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32. EMQ. Anti-D.
Lead-in.
The following scenarios relate to Rhesus prophylaxis and
anti-D.
Abbreviations.
Ig: immunoglobulin.
FMF: feto-maternal
haemorrhage.
RAADP: routine antenatal
anti-D prophylaxis.
RBC: red blood cells.
RhAI: Rhesus D alloimmunisation.
BSE: bovine spongiform encephalopathy.
CJD: Creutzfeldt - Jakob disease.
There is no option list to force good technique!
Scenarios.
1)
What proportion of
the Caucasian population in the UK has Rh –ve blood group?
2)
What proportion of
the Rhesus +ve Caucasian population is homozygous for RhD?
3)
What is the chance
of a Rh –ve woman with a Rh +ve partner having a Rh –ve child?
4)
When was routine
postnatal anti-D prophylaxis introduced in the UK?
5)
Where does anti-D for prophylactic use come
from?
6)
How many deaths
per 100,000 births were due to RhAI up to 1969?
7)
How many deaths
per 100,000 births were due to RhAI in 1990?
8)
Anti-D was in
short supply in 1969. Which non-sensitised Rh –ve primigravidae with Rh +ve
babies would not be given anti-D as a matter of policy?
9)
List the possible
reasons that a Rhesus –ve mother with a Rhesus +ve baby who does not receive
anti-D might not become sensitised?
10)
What is the UK
policy for the administration of anti-D after a term pregnancy?
11)
What is the
alternative name of the Kleihauer test?
12)
What does the
Kleihauer test do?
13)
How does the
Kleihauer test work and what buzz words should you have in your head?
14)
When should a
Kleihauer test be done after vaginal delivery?
15)
What blood
specimen should be sent to the laboratory for a Kleihauer test?
16)
What steps should
be taken to prevent sensitisation in the woman whose blood group is RhDu
and whose baby is Rh +ve?
17)
The Kleihauer test is of value
in helping to decide if antenatal vaginal bleeding or abdominal pain are due to
placental abruption, with a +ve test confirming FMH and making abruption highly
probable.
True/False
18)
When should anti-D
be offered?
19)
When should a
Kleihauer test be considered?
20)
How often does the
word “considered” feature in the GTG?
21)
A Rhesus –ve woman
miscarries a Rh +ve fetus at 18 week’s gestation. What should be done about
Rhesus prophylaxis?
22)
A Rhesus –ve woman
miscarries a Rh +ve fetus at 20 week’s gestation. What should be done about
Rhesus prophylaxis?
23)
Which potentially
sensitising events are mentioned in the GTG?
24)
What factors are listed in the GTG as
particularly likely to cause FMH > 4 ml
25)
A woman has recurrent bleeding from 20
weeks. What should be done about Rh prophylaxis?
26)
What are the key messages about giving
RAADP?
33. EMQ. Headache.
Lead-in.
The following
scenarios relate to headache in pregnancy.
Pick one option from the option list.
Each option can be used once, more than once or not at
all.
Option list.
1. abdominal migraine
2. analgesia overuse headache aka medication overuse headache
3. bacterial meningitis
4. benign intracranial hypertension
5. BP check
6. cerebral venous sinus thrombosis
7. chest X-ray
8. cluster headache
9. severe PET / impending eclampsia
10. malaria
11. meningococcal meningitis
12. methyldopa
13. methysergide
14. migraine
15. MRI brain scan
16. nifedipine
17. nitrofurantoin
18. pancreatitis
19. sinusitis
20. subdural haematoma
21. subarachnoid haemorrhage
22. tension headache
23. ultrasound scan of the abdomen
Scenario 1.
A 40-year-old para 3 is
admitted at 38 weeks by ambulance with severe headache of sudden onset. She
describes it as “the worst I’ve ever had”. Which diagnosis needs to be excluded
urgently?
Scenario 2.
A 32-year-old para 1 has
recently experienced headaches. They are worse on exercise, even mild exercise
such as walking up stairs. She experiences photophobia with the headaches.
Which is the most likely diagnosis?
Scenario 3.
A woman returns from a
sub-Saharan area of Africa. She develops severe headache, fever and rigors.
What diagnosis should particularly be in the minds of the attending doctors?
Scenario 4.
A woman at 37 weeks has developed headaches. They
particularly occur at night without obvious triggers. They occur every few days
and she then has
Scenario 5.
A primigravida has had headaches on a regular basis for
many years. They occur most days, are bilateral and are worse when she is
stressed. What is the most likely diagnosis?
Scenario 6.
A woman complains of recent
headaches at 36 weeks. The history reveals that the headaches started soon
after she began treatment with a drug prescribed by her GP. Which is the most
likely of the following drugs to be the culprit: 7. methyldopa, methysergide, nifedipine and Nitrofurantoin?
Scenario 7
A woman is booked for Caesarean
section and wishes regional anaesthesia. She had severe headache due to dural
tap after a previous Caesarean section. She wants to take all possible steps to
reduce the risk of having this again. Which of epidural and spinal anaesthesia
has the lower risk of causing dural tap headache?
Scenario 8
A 25-year-old primigravida
complains of headaches which started two weeks before when she attends for her
20 week scan. There is no significant history of previous headache. The pain
occurs behind her right eye and she describes it as severe and “stabbing” in
nature. The pain is so severe that she cannot sit still and has to walk about.
She has noticed that her right eye becomes reddened and “watery” during the
attack and her nose is “runny”. The attacks have no obvious trigger and mostly
occur a few hours after she has gone to sleep. The usually last about 20
minutes. She has no other symptoms. She smokes 20 cigarettes a day but does not
take any other drugs, legal or otherwise. What is the most likely diagnosis?
Scenario 9
A woman has a 5-year history of
unilateral, throbbing headache often preceded by nausea, visual disturbances,
photophobia and sensitivity to loud noise. What is the most likely diagnosis?
Scenario 10
A primigravida is admitted at 38 weeks complaining of
headache, abdominal pain and a sensation of flashing lights. What would be the
appropriate initial investigation?
Scenario 11
A woman with BMI of 35 attends for her combined Downs
syndrome screening test. She complains of pain behind her eyes. The pain is
worst last thing at night before she goes to sleep or if she has to get up in
the night. She has noticed she has noticed horizontal diplopia on several
occasions. She has no other symptoms. Examination shows papilloedema.
Scenario 12
A grande multip of 40 years experienced sudden-onset,
severe headache, vomited several times and then collapsed, all within the space
of 30 minutes. She is admitted urgently in a semi-comatose state. Examination
shows neck-stiffness and left hemi-paresis.
Scenario 13.
What did the MMR include as
“red flags” for headache in pregnancy? These are not on the option list – you
need to dig them out of your head.
34. EMQ.
Obstetric cholestasis. (OC). 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.
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?
35. Obstetric
cholestasis. (OC). Diagnosis & management.
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.
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