Monday, 8 August 2016

Tutorial 8th. August 2016



8 August 2016.

59
EMQ. Down’s syndrome screening
60
SBA. Flu and pregnancy
61
EMQ. Labour 1
62
SBA. Grades of recommendations
63
SBA. Non-invasive testing. NIPT.

59.   EMQ. Down’s syndrome screening.
Lead-in.
The following scenarios relate to screening for Down’s syndrome.
Pick one option from the option list. Each option can be used once, more than once or not at all.
Abbreviations.
DS.        Down’s syndrome.
NSC:      National Screening Committee
Option list.
a.       1 in 2
b.      1 in 5
c.       1 in 10
d.      1 in 20
e.       1 in 40
f.        1 in 250
g.       1 in 400
h.      1 in 1,000
i.         5 mm.
j.         6 mm.
k.       7 mm.
l.         8 mm.
m.    10 mm.
n.      1%
o.      2%
p.      5%
q.      10%
r.        80%
s.       95%
t.        90%
u.      95%
v.       higher
w.     lower
x.       true
y.       false
z.       none of the above.
Scenario 1.
What is the age-related risk of DS at 20 years?
Scenario 2.
What is the age-related risk of DS at 30 years?
Scenario 3.
What is the age-related risk of DS at 35 years?
Scenario 4.
What is the age-related risk of DS at 40 years?
Scenario 5.
What is the age-related risk of DS at 45 years?
Scenario 6.
AFP levels are lower in Ds.
Scenario 7
Inhibin levels are raised in DS.
Scenario 8
Oestriol levels are raised in DS.
Scenario 9
β-hCG levels are raised in DS.
Scenario 10
1st. trimester PAPP-A levels are lower in DS.
Scenario 11
2nd. trimester PAPP-A levels are normal in DS.
Scenario 12
What are the NSC’s standards for an acceptable screening test in terms of detection and screen +ve rates?
Option list.
A
DR > 70%; screen +ve rate < 5%
B
DR > 75%; screen +ve rate < 4%
C
DR > 80%; screen +ve rate < 3%
D
DR > 85%; screen +ve rate < 3%
E
DR > 90%; screen +ve rate < 2%
Scenario 13
Which of the following tests meet the NSC’s standards for detection and screen +ve rates?
There is no option list. Write the tests you know that fit.
Scenario 14
What are NICE’s current recommendations about Down’s syndrome screening?
There is no option list. Write down all the things you can think of.
Scenario 15
 What characteristic is described in relation to the occipital hairline in DS?
Scenario 16
 What characteristic is described in relation to the frontal hairline in DS?
Scenario 17
 What is the incidence of congenital heart anomaly in DS?
Scenario 18
Which is the most common congenital heart anomaly in DS?
Scenario 19
 Which major haematological condition is more common in those with DS?
Scenario 20
 Which major neurological condition is more common in middle age in those with DS?
Scenario 21
 Which spinal anomaly is more common in DS and of concern to anaesthetists?
Scenario 22
Lead in. I have added the following scenarios as I have been told by Deepak Bhenki that there were questions along these lines in the exam.
A woman aged 20 has a routine 1st. trimester DS screening test at 11 weeks. The midwife taking her details enters her age incorrectly on the form as 30 years. What effect will this have on the risk given when the result is available?



Scenario 23
A woman aged 40 has a routine 1st. trimester DS screening test at 11 weeks. The midwife taking her details enters her age incorrectly on the form as 20 years. What effect will this have on the risk given when the result is available?
Scenario 24
A woman aged 25 has a routine 1st. trimester DS screening test at 11 weeks. The laboratory has a problem with the assay for PAPP-A levels and ends up with a result that is half of what it should be. What effect will this have on the risk given when the result is available?

60.   SBA. Flu and pregnancy
Question 1.
Lead-in
What did MBRRACE say about flu & pregnancy in its first report in 2014?
Option List
Pick the best option from the following list.
A.       
1 in 11 women died from flu
B.       
1 in 11 women died from flu and flu vaccination could have prevented ½ of the deaths
C.       
1 in 21 women died from flu
D.       
1 in 21 women died from flu and flu vaccination could have prevented ½ of the deaths
E.        
1 in 51 women died from flu
F.        
1 in 51 women died from flu and flu vaccination could have prevented ½ of the deaths
Question 2.
Lead-in
How many types of flu virus are recognised?
Pick the best option from the following list.
Option List
A.       
3
B.       
5
C.       
10
D.       
15
E.        
>100
Question 3.
Lead-in
Why can’t we have a universal flu vaccine?
Pick the statements from the following list that are true.
List of statements.
A.       
The main surface antigens are haemagglutinin and neuraminidase
B.       
The main surface antigens are haemolysin and neuroxidase
C.       
The main surface antigens frequently
D.       
The main core antigens change frequently, rendering existing vaccines impotent
E.        
The big drug companies avoid making a universal vaccine for financial reasons.
Option List
1.        
A + C + D + E
2.        
A + C
3.        
A + D + E
4.        
B + C
5.        
 B + D + E
Question 4.
Lead-in
When is flu’ most often a problem in the UK?
Pick the best option from the following list.
Option List
A.       
Spring
B.       
Summer
C.       
Autumn
D.       
Winter
E.        
None of the above.
Question 5.
Lead-in
How is flu spread?
Pick the best option from the following list.
Option List
A.       
via aerosol or droplets from respiratory tract of an infected person
B.       
via aerosol or droplets from respiratory tract or direct contact with respiratory secretions  of an infected person
C.       
from getting drenched in cold winter showers
D.       
from thinking lascivious thoughts
E.        
from toilet seats
Question 6.
Lead-in
What is the incubation period for flu?
Pick the best option from the following list.
Option List
A.       
1 – 3 days
B.       
1 – 7 days
C.       
5 – 10 days
D.       
up to 2 weeks
E.        
up to 3 weeks
Question 7.
Lead-in
Who decides which viruses will be used in the vaccine for seasonal flu?
Pick the best option from the following list.
Option List
  1.  
DOH
  1.  
JCVI
  1.  
the Prime Minister
  1.  
the vaccine manufacturers
  1.  
WHO
Question 8.
Lead-in
How long has flu vaccination been recommended in the UK?
Pick the best option from the following list.
Option List
A.       
since the 1950s
B.       
since the 1960s
C.       
since the 1970s
D.       
since the 1980s
E.        
since the 1990s
Question 9.
Lead-in
What is the recommendation about when the vaccine should be given?
Pick the best option from the following list.
Option List
A.       
May - July
B.       
June - August
C.       
July - September
D.       
August - October
E.        
September - November
Question 10.
Lead-in
What advice is given about vaccination in pregnancy?
Pick the best option from the following list.
Option List
A.       
flu vaccine is potentially teratogenic and should be avoided before 16 weeks
B.       
the vaccine contains an attenuated virus with no evidence of risk in pregnancy
C.       
the vaccine recommended for pregnancy has no live viral material and all pregnant women are encouraged to have the seasonal vaccine
D.       
flu vaccine contains an attenuated virus with minimal risk, but the anti-viral drug Tamiflu is given with the vaccine to eliminate any risk of harm
Question 11.
Lead-in
What is the H1N1 virus?
Pick the best option from the following list.
Option List
A.       
The avian virus which causes outbreaks of “bird flu”
B.       
The virus associated with “swine” flu, which caused a pandemic in 2009
C.       
The virus associate with MERS, currently causing deaths particularly in Saudi Arabia
D.       
The virus associated with simian flu
E.        
The virus associated with the pandemic of 1915.
Question 12.
Lead-in
What advice should be given to pregnant women about protection against the H1N1 virus?
Pick the best option from the following list.
Option List
A.       
to have vaccination against H1N1 in addition to the seasonal vaccine
B.       
to have vaccination against H1N1 in preference to the seasonal vaccine
C.       
to await evidence of epidemic H1N1 flu and then have vaccination against H1N1
D.       
to have the seasonal vaccine as it gives good protection against H1N1
E.        
not to have any flu vaccination, but to take antiviral drugs if symptoms of flu occur
Question 13.
Lead-in
Pick the best option from the following list.
Which of the following conditions have been linked to flu in pregnancy?
Conditions.
A.       
­ risk of flu complications for the mother
B.       
­ risk of low birthweight
C.       
­ risk of maternal death
D.       
­ risk of perinatal death
E.        
­ risk of  prematurity
Option List
1
A + C+ D + E
2
A + B + C+ D
3
A + C + D
4
A + C+ D + E
5
A + B + C+ D + E
Question 14.
Lead-in
What is the estimated uptake of flu vaccination by pregnant women in the UK?
Pick the best option from the following list.
Option List
A.       
20-30%
B.       
30-40%
C.       
40-50%
D.       
50-60%
E.        
> 60%
Question 15.
Lead-in
How many maternal deaths were reported by MBRRACE for the years 2012 - 2013?
Pick the best option from the following list.
Option List
A.       
0
B.       
5
C.       
10
D.       
15
E.        
20
Question 16.
Lead-in
With regard to the probable explanation for the numbers of maternal deaths from ‘flu in 2012 and 2013,        which, if any, of the following statements is true?
Option List
A.       
the numbers reflected increased prevalence of ‘flu
B.       
the numbers reflected reduced prevalence of ‘flu
C.       
the numbers reflected improved uptake of ‘flu vaccine in pregnancy
D.       
the numbers reflected the introduction of Tamiflu for pregnant women with ‘flu
E.        
none of the above

61.   EMQ. Labour ward.
Read each of the following clinical scenarios and choose the best management from the list of options. Each option may be used once, more than once or not at all.
Option list.
A.      anticipate spontaneous vaginal delivery
B.      perform biophysical profile.
C.      perform fetal scalp pH sampling
D.      perform fetal buttock pH sampling
E.       arrange flow cytometry to assess for feto-maternal haemorrhage
F.       correct maternal diabetic keto-acidosis and re-assess
G.      exclude cephalo-pelvic disproportion
H.      check for descent with contraction / maternal pushing
I.        give steroids to promote fetal lung maturation.
J.        deploy the APH protocol
K.       start syntocinon
L.       use the Kiwi
M.    use the silastic ventouse
N.      use Kiel land forceps
O.     use Neville-Barnes forceps
P.       use Spencer Wells forceps
Q.     breech extraction
R.      internal podalic version and breech extraction
S.       elective Caesarean section
T.       emergency Caesarean section
U.      Caesarean hysterectomy
V.      resign your post and become a Cistercian monk / nun
W.    None of the above.

1.     A primigravida with a 10 year history of IDDM is admitted at 30 weeks with diabetic ketoacidosis. The fetal heart rate is noted to 160 b.p.m. with loss of beat-to-beat variability and variable, late decelerations. What action will you take in relation to the fetal condition.
2.     A primigravida with a 10 year history of IDDM with good glycaemic control has been actively pushing in the second stage of labour for 2 hours and is exhausted. The first stage of labour lasted 8 hours. She has an effective epidural in place. The baby feels of average size and the scan estimate was of a birthweight of 7 – 8lbs. 1/5 of the fetal head is palpable abdominally. The position is OA with the head at the spines and a moderate degree of caput and moulding. What action, if any, will you take to expedite the delivery?
3.     A 35-year-old woman has had two normal deliveries of babies weighing 7 and 8 lb. ten years before. Diabetes has been diagnosed in this pregnancy and has been well-controlled with diet. She is admitted at 39 weeks in spontaneous labour. The cervix is fully dilated and a flexed breech presentation is noted. The fetal heart rate is 100 beats per minute with poor variability and late decelerations. There is thick, fresh meconium. What action, if any, will you take to expedite the delivery?
4.     A 35-year-old primigravida is admitted at 34 weeks with SROM and obvious liquor draining. Abdominal examination shown breech presentation. Her temperature is normal and her condition is good. A CTG shows a normal pattern. What will be your first action?
5.     A 40-year-old woman has had two normal deliveries of babies weighing 7 and 8 lb. ten years before. After a first stage lasting 5 hours she has sudden pain and fresh bleeding. The fetal heart rate drops to 90 beats per minute with no recovery over a period of 5 minutes. The cervix is noted to be almost fully dilated with only a thin rim of cervix anteriorly. The position is OA with the head 2 cm. below the spines. There is minimal caput and moulding. What action will you take to expedite the delivery after sending a midwife to call for help?
6.     A primigravida has spontaneous onset of labour at 40 weeks. The first stage last for 15 hours. After active pushing in the second stage for 2 hours, she is becoming tired. The CTG is normal and the liquor is clear. Abdominal examination shows 1/5 of the fetal head to be palpable. The presenting part is at the ischial spines. The position is occipito-transverse with moderate caput and moulding. There is no descent of the presenting part with contractions and pushing. What action, if any, will you take to expedite the delivery?
7.     A primigravida has spontaneous onset of labour at 40 weeks. The first stage last for 15 hours. After active pushing in the second stage for 2 hours, she is becoming tired. The CTG is normal and the liquor is clear. Abdominal examination shows 0/5 of the fetal head to be palpable. The presenting part is at the ischial spines. The position is occipito-transverse with moderate caput and moulding. There is some descent of the presenting part with contractions and pushing. What action, if any, will you take to expedite the delivery?
8.     A primigravida at 32 weeks has been pushing in the second stage for 90 minutes. The first stage lasted for 6 hours and was of spontaneous onset. Maternal condition is good. You have been summoned as the CTG shows bradycardia, loss of variability and late decelerations. The head is not palpable abdominally and the position is occipito-anterior and the station 1 cm. below the ischial spines. What action, if any, will you take to expedite the delivery?
9.     A woman of 45 years from an Irish traveller family has had 5 normal deliveries of babies weighing from 4 to 4.5kg. The youngest child is 10 years old. She is admitted in advanced labour having had no antenatal care. Examination shows the cervix to be fully dilated with the head presenting 1 cm above the spines in an occipito-anterior position. There is moderate caput and moulding. She is obese, but the fetal head is thought to be 1/5 palpable. There is evidence of fetal compromise with loss of variability and late decelerations. What action, if any, will you take to expedite the delivery?
10.   A woman of 30 years with a history of elective Caesarean section for breech presentation in her only previous pregnancy is in labour after a consultant decision that her wish for VBAC is appropriate. After 6 hours in labour she complains of sudden lower abdominal pain. A small amount of fresh blood is noted. The CTG shows sudden onset of compromise with a rate of 80 beats per minute, loss of variability and variability. What action, if any, will you take to expedite the delivery?

62.   EMQ. Grades of recommendations.
This question relates to the Green-top and other RCOG guidelines and how evidence is evaluated and given importance. This is the sort of esoteric stuff that could be included in an EMQ or SAQ.
Question 1.
Lead-in
Which of the following statements, if any, are true.
i.      CNST requires consultants to follow the advice in GTGs
ii       CNST requires consultants to follow the advice in GTGs, unless the consultant has phoned the CNST to obtain permission for alternative management
iii.    Consultants deviating from the advice in a GTG should send details to the hospital lawyer
iv.    Consultants are responsible for the decisions they make about patient care and can choose to deviate from the advice in GTGs.
v.     A consultant choosing different care for a patient to that in a guideline should fully document the decision at the time it is made.
Pick the option from the list below that best fits.
Option List
  1.  
i
  1.  
ii
  1.  
iii
  1.  
iii + iv
  1.  
iv + v
Question 2.
Lead-in
Grade A recommendations have specific requirements. Choose the option from the list below that best fits.
Option List
  1.  
a positive Cochrane review is a requirement for a Grade A recommendation
  1.  
a Grade A recommendation can be based on high-quality systematic reviews of case series
  1.  
a Grade A recommendation can be based on a single systematic review or RCT.
  1.  
a Grade A recommendation must include a meta-analysis or systematic review of RCTs
  1.  
a Grade A recommendation can be an extrapolation from studies graded 2++ or better.
Question 3.
Lead-in
Which, if any, of the following statements are true about Grade A recommendations.
i.      ≥ 1 meta analysis or systematic review can be sufficient for a Grade A recommendation
ii.     ≥ 1 RCT rated 1++ and applicable to the target population can be sufficient for a Grade A recommendation
iii.    a systematic review of RCTs can be sufficient for a Grade A recommendation
iv.    studies rated as 1+ which are applicable to the target population and with consistent  results can be sufficient for a Grade A recommendation
Option List
  1.  
i
  1.  
i + ii
  1.  
i + iii
  1.  
all of the above
  1.  
none of the above
Question 4.
Lead-in
What other grades are there?
Question 5.
Lead-in
What criteria are associated with these other grades?

63.         EMQ.  Non-invasive prenatal testing. NIPT.
Abbreviations.
CAH:           congenital adrenal hyperplasia
DSD:           disorder of sexual development
NIPD:          non-invasive prenatal diagnosis
Question 1.
Lead-in
What is the definition of NIPT?
Option List
G.       
any test to detect fetal anomaly, disease or significant problem that does not involve invasive testing of the mother
H.       
any test to detect fetal anomaly, disease or significant problem that does not involve invasive testing of the mother, excluding TVS
I.         
any test for fetal chromosomal anomaly that does not involve invasive testing of the mother
J.         
any test for fetal chromosome or genetic anomaly that does not involve invasive testing of the mother.
K.        
none of the above
Question 2.
Lead-in
What is the potential of NIPT using cffDNA and RNA?
Option List
F.        
description of the full fetal genome
G.       
description of the full fetal genome with the exception of disorders arising from mitochondrial DNA
H.       
description of the full fetal genome with the exception of disorders arising from mitochondrial RNA
I.         
description of the full fetal genome and most structural anomalies
J.         
none of the above
Question 3.
Lead-in
Which of the following statements is true?
Option List
F.        
cffDNA is found in maternal serum in greater quantities than maternal cell-free DNA
G.       
cffDNA is found in maternal serum in  lesser quantities than maternal cell-free DNA
H.       
the quantity of cffDNA rises throughout pregnancy, peaking at placental separation
I.         
cffDNA diminishes after placental delivery but remains detectable for at least 6 weeks
J.         
cffDNA diminishes after placental delivery but remains detectable for at least 1 year
Question 4.
Lead-in
Which, if any, of the following statements are true?
Statements.
1.       cffDNA is usually detectable from 4-5 weeks’ gestation
2.       cffDNA is not usually detectable at gestations < 12 weeks
3.       the quantity of cffDNA rises throughout pregnancy, peaking at placental separation
4.       cffDNA diminishes after placental delivery but remains detectable for at least 6 weeks
5.       cffDNA diminishes after placental delivery but remains detectable for at least 1 year
Option List
A.       
1
B.       
2
C.       
3
D.       
4
E.        
5
F.        
1 + 3
G.       
1 + 4
H.       
1 + 5
I.         
2 + 3
J.         
2 + 4
K.        
2 + 5
Question 5.
Lead-in
Which, if any, of the following statements is true about cffDNA in maternal blood?
Statements.
1.       cffDNA originates in the placenta, not the fetus
2.       cffDNA originates in fetal squames
3.       cffDNA originates in fetal blood cells
4.       cffDNA occurs in maternal blood due to trans-membrane osmosis
5.       cffDNA occurs in maternal blood due to feto-maternal transfusion
Option List
A.       
1
B.       
2
C.       
3
D.       
4
E.        
5
F.        
1 + 4
G.       
2 + 4
H.       
2 + 5
I.         
3 + 5
Question 6.
Lead-in
Which. if any, of the following statements are true?

Statements.
1.       tests using cffDNA are based on detecting paternally-derived fetal DNA in maternal blood.
2.       tests using cffDNA are based on detecting maternally-derived fetal DNA in maternal blood.
3.       tests using cffDNA are based on detecting DNA from the fetal Y chromosome.
4.       tests using cffDNA may involve shotgun sequencing.
5.       tests using cffDNA may involve shotgun nuptials.
Option List
A.       
1
B.       
2
C.       
3
D.       
4
E.        
5
F.        
1 + 4
G.       
1 + 5
H.       
2 + 4
I.         
2 + 5
J.         
3 + 4
K.        
3 + 5
Question 7.
Lead-in
Which. if any, of the following statements are true?
Option List
A.       
detection of the SRY sequence in cffDNA means that the fetus is female
B.       
detection of the SRY sequence in cffDNA means that the fetus is male
C.       
detection of the SRY sequence in cffDNA means that the fetus is male unless it has a DSD
D.       
detection of the SRY sequence in cffDNA means that the fetus has Klinefelter’s syndrome
E.        
detection of the SRY sequence in cffDNA means that the fetus has 45X0/46XY mosaicism.
Question 8.
Lead-in
Which. if any, of the following statements are true?
Option List
There is none.
A.       
Rhesus D status can be determined accurately from 12 weeks’ gestation using cffDNA
B.       
Rhesus D pseudogene is more common in Africans than Caucasians
C.       
People with the RhD pseudogene are at risk of isoimmunisation.
D.       
People with the RhDu blood type may be identified as Rh-ve or Rh+ve on routing testing
E.        
People with the RhDu blood type are particularly prone to isoimmunisation
Question 9.
Lead-in
Which. if any, of the following statements are true in relation to cffDNA in maternal blood?
Option List
A.       
Checking the fetal RhD status is best left until > 16 weeks’ gestation
B.       
Checking the fetal Kell status is not yet routinely available
C.       
Checking the fetal Kell status is best left until > 20 week’s gestation
D.       
Routine screening of Rh –ve women for fetal RhD status reduces the use of RAADP by up to 10%
E.        
Routine screening of Rh –ve women for fetal RhD status reduces the use of RAADP by up to 40%
Question 10
Lead-in
List the other situations in which cffDNA in maternal serum can be used for clinical benefit.
Other questions.
1.     cffDNA levels in maternal blood are raised in pregnancies affected by Down’s syndrome.
True / False.
2.     screening for Down’s syndrome using cffDNA has both sensitivity and specificity close to 100%
True/ False
3.     What is the value of cffDNA in women at risk of having a baby with CAH?.
4.     How might cffDNA be used to screen for conditions such as cystic fibrosis?
 5.    What is the role of amniocentesis if a cffDNA screen for a condition such as cystic fibrosis proved +ve?
6.     cffDNA screening for achondroplasia and thanatophoric dysplasia is now available on the NHS for women at risk of an affected baby. True / False
7.     What is meant by “contingent” screening using cffDNA in relation to Down’s syndrome?
8.     What is an “allele”?
9.     What is a “wild-type” allele?
10.   What is the alternative to a “wild-type” allele?


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