Contact us.
32
|
EMQ. Surrogacy
|
33
|
EMQ. Hepatitis B
|
34
|
EMQ. Confidentiality
& consent
|
35
|
SBA. Coeliac disease & pregnancy
|
36
|
EMQ. Anti-D
|
32. Surrogacy.
Abbreviations.
ART: assisted reproductive technology
CF: commissioning father
CM: commissioning mother
CPs: commissioning parents
PO: parental order
SM: surrogate mother
SSAEW: Surrogacy Supervisory Authority England and Wales.
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.
True/False
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. True / False
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. True/False
Scenario 19.
A lesbian couple in a stable, co-habiting relationship can be CPs and
become the legal parents of the child of a SM. True/False
Scenario 20.
CPs are likely to get faster legal status as the legal parents through
application for a PO rather than applying for adoption. True/False
33. Topic. Hepatitis B and pregnancy.
Lead-in.
These scenarios relate to hepatitis and pregnancy.
Abbreviations.
CNP: Handbook
of Obstetric Medicine. 5th. Edition. Catherine Nelson-Piercy. CRC
Press. 2015. HAV: hepatitis
A virus
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
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
HCV: hepatitis C virus
HEV: hepatitis E virus
HSV: herpes simplex virus
VT: vertical transmission
Option
list.
A.
|
acyclovir
|
B.
|
divorce
|
C.
|
HBcAg +ve
|
D.
|
HBeAg +ve
|
E.
|
HbsAg +ve
|
F.
|
HBsAg +ve; HBsAb –ve; HBcAb –ve; HBeAg +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.
|
HAV
|
FF.
|
HBV
|
GG.
|
HCV
|
HH.
|
HEV
|
II.
|
HSV
|
JJ.
|
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 HBV 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 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 9 months ago. What results on routine blood
testing would show 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.
How common is chronic HBV carrier status in UK
pregnant women?
Scenario
8.
What is the risk of death from chronic HBV carrier
status?
Scenario
9.
A primigravid woman at 8 weeks gestation is found to
be non-immune to HBV. She has recently married and her husband is a chronic
carrier. What should be done to protect her from infection?
Scenario
10.
A woman is a known carrier of HBV. What is the risk of
vertical transmission in the first trimester?
Scenario
11.
What is the risk of the neonate who has been infected
by vertical transmission becoming a carrier without treatment?
Scenario
12.
Should antiviral maternal therapy in the 3rd.
trimester be considered for women with HBeAg or high viral load?
Scenario
13.
How effective is hepatitis B prophylaxis for the
neonate in preventing chronic carrier status as a result of vertical transmission?
Scenario
14.
Can a woman who is a chronic HBV carrier breastfeed
safely?
Scenario
15.
Hepatitis B infection is the most dangerous of the viral hepatitis
infections in pregnancy.
Scenario
16.
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
17.
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
18.
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!
Scenario
19.
Does elective Cs before labour and with the membranes
intact reduce the vertical transmission rate?
Scenario
20.
Which hepatitis virus normally produces a mild
illness, but represents a major risk to pregnant women, with a mortality rate
of up to 5%?
Scenario
21.
A pregnant woman has a history of viral hepatitis and
informs the midwife at booking that she is a carrier and that she has a
significant risk of cirrhosis and has been advised not to drink alcohol. Which
is the most likely hepatitis virus?
Scenario
22.
Which hepatitis virus is an absolute contraindication
to breastfeeding after appropriate treatment of the infected mother and
prophylaxis for the baby?
Scenario
23.
Which hepatitis virus is linked to an increased risk
of obstetric cholestasis?
34. Confidentiality
& consent.
Lead-in.
The following scenarios relate to confidentiality.
For each, select the number that best fits the scenario.
Pick one option from the option list.
Each option can be used once, more than once or not at
all.
Option list.
This EMQ has no option list. This is to make you decide
your answers, which is what you are advised to do in the exam before you look
at the option list.
Scenario 1.
A 15-year-old girl attends the
TOP clinic requesting TOP. She is assessed as Fraser competent. After full
discussion arrangements are made for her admission for TOP. She does not wish
her parents to be informed. Her mother attends clinic 1 hour after the child
has left. She demands full information about her daughter. The consultant has
delegated you to deal with her. Which option best fits the action you
will take?
Scenario 2.
A 17-year-old A-level student
attends the gynaecology clinic requesting TOP. She is accompanied by her
30-year-old mathematics teacher, who is her lover and wishes to give consent. Which
option best fits the action you will take?
Scenario 3.
A 12-year-old girl attends the
gynaecology clinic with her mother seeking contraceptive advice. She has an
18-year-old boyfriend whom the parents like and she wishes to start having sex.
Which option best fits the action you will take?
Scenario 4.
A 15-year-old girl who is Fraser competent is referred to
the gynaecology clinic with a complaint of vaginal discharge. She reveals that
she has been having consensual sexual intercourse for six months with her
18-year-old boyfriend. She asks for advice about suitable contraception as she
is happy in the relationship and wants to continue to have sex. Which option
best fits the action you will take?
Scenario 5.
You are the new oncology consultant and have just
operated on the wife of a local General Practitioner for suspected ovarian
cancer. The diagnosis is confirmed and you proceed with appropriate surgery. On
completion of the operation you go to the surgeon’s room for a coffee. The
senior consultant anaesthetist who was not involved in theatre but is the
Medical Director and tells you he is a close friend of the woman, asks what the
diagnosis and prognosis are. Which option best fits the action you will take?
Scenario 6.
You are phoned by a doctor
looking for information about his wife’s results from the booking clinic she
attended two weeks ago. He says that she has given consent for disclosure. She
has given a history of 2 terminations but no other pregnancies. She is Rhesus
negative, but has Rhesus antibodies. Which option best fits the action
you will take?
Scenario 7
You are phoned by a doctor
looking for information about his wife’s results from the booking clinic she
attended two weeks ago. He says that she has given consent for disclosure. Her
serology tests have proved +ve for syphilis. You have spoken to the consultant
bacteriologist who says that they have run confirmatory tests and they are +ve
too. He is sure the woman has active syphilis. Which option best fits
the action(s) you will take?
Scenario 8
A 15-year-old girl attends the
TOP clinic requesting TOP. She is assessed as Fraser competent. After full
discussion arrangements are made for her admission for TOP. She does not wish
her parents to be informed despite your best efforts to persuade her. Who will
give consent for the procedure?
Scenario 9
An immature 15-year-old girl
attends the gynaecology clinic requesting TOP. She is accompanied by her
25-year-old sister who is a lawyer with whom she has been staying since she
knew she was pregnant. She does not want her parents to be informed. The girl
is assessed as not Fraser competent. The sister says that she is happy to act
in loco parentis and to give consent. Which option best fits the
action(s) you will take?
Scenario 10
A 25-year-old woman with Down’s syndrome attends the
clinic accompanied by her mother. She has menorrhagia and copes badly with the
hygiene aspects. The menorrhagia is bad enough for her now to be on treatment
for iron-deficiency anaemia. She has tried all the standard medical methods. To
complicate the problem, she has become close friends with a young man she has
met at College, to which she travels independently each weekday. Her mother
fears that she may already be involved in sexual activity and cannot get an
accurate answer from her about it. The mother is keen for her to have
hysterectomy to deal with both problems. If you agree that the surgery is
appropriate, who can give consent?
Scenario 11
A 25-year-old woman with Down’s syndrome is admitted from
College after collapsing. The clinical features are of ectopic pregnancy and
she states that she has UPSI with her boyfriend of six months. She has
tachycardia and hypotension and it is felt that she should have urgent surgery.
You reckon that she is not competent to consent for surgery. Who can give
consent?
Scenario 12
A 25-year-old woman with Down’s syndrome is admitted from
College after collapsing. The clinical features are of ectopic pregnancy and
she states that she has UPSI with her boyfriend of six months. She has
tachycardia and hypotension and it is felt that she should have urgent surgery.
You reckon that she is not competent to consent for surgery. What limits are
there on the surgery?
Scenario 13.
You are the SpR on call and are asked to see a
10-year-old child in the A&E department. She has been brought because of
vaginal bleeding. She is accompanied by her parents who give a story of her
injuring herself falling of her bike. Examination shows vaginal bleeding and
you think the hymen looks torn. You suspect sexual abuse and don’t believe the
parents’ story. When this is discussed with the parents they say it is
impossible and that they do not want involvement of police or social workers. What
action will you take?
Scenario 14.
You are the SpR in theatre with your consultant. Mrs Mary
White, age 45, has been listed for abdominal hysterectomy and bilateral
salpingo-oophorectomy – she has a long history of menorrhagia that has not
responded to conservative measures. Her mother had ovarian cancer diagnosed at
55 and died from the disease 3 years later. A 10 cm., solid tumour of the left
ovary is found on opening the abdomen. Which of the following options is the
correct course of action?
A
|
close the abdomen, see her to explain the findings and
book a follow-up appointment in the gynaecological clinic to discuss further
management
|
B
|
close the abdomen, arrange to see her to explain the
findings and refer to the gynaecological oncologist to discuss further
management
|
C
|
continue with the operation, but don’t remove the left
ovary
|
D
|
continue with the operation, removing the uterus and
both ovaries and tubes
|
E
|
continue with the operation, removing the uterus and
both ovaries and tubes and obtaining peritoneal washings
|
F
|
ask the gynaecological oncologist to attend to perform
definitive surgery on the basis that the cyst is likely to be malignant
|
G
|
phone the legal department for advice
|
H
|
phone the Court of Protection for advice
|
Scenario 15.
You are an SpR in theatre with
your consultant.
Mrs Mary White, age 45, has
been listed for abdominal hysterectomy and bilateral salpingo-oophorectomy –
she has a long history of menorrhagia that has not responded to conservative
measures. Her mother had ovarian cancer diagnosed at 55 and died from the
disease 3 years later.
You perform examination under
anaesthesia prior to the abdomen being opened. You find a 10 cm., mass to the
left of the uterus. It feels solid. There is no evidence of ascites or other
pathology.
Which of the following options is the correct
course of action?
A
|
Cancel the operation and
arrange review in the gynaecology department in 6 weeks
|
B
|
Cancel the operation and
arrange review by the oncology team
|
C
|
Cancel the operation and
arrange an urgent scan
|
D
|
Continue with the planned
procedure
|
E
|
Ask the gynaecological
oncologist to attend theatre to examine the patient and advise
|
F
|
Perform laparoscopy to
identify the nature of the mass
|
G
|
Phone the legal department
|
35. SBA. Coeliac
disease & pregnancy
Coeliac disease and pregnancy.
Abbreviations.
AGA: anti-gliadin
antibodies
CD: coeliac disease.
EMA: anti-endomysial
antibodies.
FGR: Fetal growth
restriction.
IgA: immunoglobulin A
IgG.
tTGA: anti-tissue
transglutaminase antibody.
Question 1.
Lead-in
What is
coeliac disease?
Option List
A.
|
allergy
to gluten
|
B.
|
malabsorption due to large bowel inflammation
|
C.
|
an auto-immune disorder triggered by gluten sensitivity
causing villous atrophy of the descending colon in individuals with a genetic
predisposition
|
D.
|
an auto-immune disorder triggered by gluten sensitivity
causing villous atrophy of the gastric mucosa in individuals with a genetic
predisposition
|
E.
|
an auto-immune disorder triggered by gluten sensitivity
causing villous atrophy of the small bowel in individuals with a genetic
predisposition
|
Question 2.
Lead-in
What is
the prevalence of coeliac disease in women of reproductive age?
Option List
A.
|
0.1%
|
B.
|
0.5%
|
C.
|
1-2 %
|
D.
|
2-5%
|
E.
|
5-10%
|
Question 3.
Lead-in
Which of the following groups have an increased risk of
CD?
Option List
A.
|
1st.
degree relatives of those with CD
|
B.
|
those with type 1 diabetes
|
C.
|
those
with iron deficiency anaemia
|
D.
|
those
with osteoporosis
|
E.
|
those
with unexplained infertility
|
Question 4.
Lead-in
Which of
the following are features of CD in the non-pregnant population?
Option List
A.
|
abdominal
bloating and pain
|
B.
|
amenorrhoea
|
C.
|
anaemia
|
D.
|
recurrent miscarriage
|
E.
|
unexplained infertility
|
Question 5.
Lead-in
How do pregnant
women with CD present most commonly?
Option List
A
|
anaemia
|
B
|
failure to gain weight in pregnancy
|
C
|
intra-uterine growth retardation
|
D
|
low BMI
|
E
|
no recognised abnormality
|
Question 6.
Lead-in
Which of
the following commonly occur in pregnant women with CD?
Option List
A
|
anaemia
|
B
|
failure to gain weight in pregnancy
|
C
|
intra-uterine growth retardation
|
D
|
low BMI
|
E
|
no recognised abnormality
|
Question 7.
How should the woman with suspected CD be investigated
initially?
Option List
A.
|
jejunal biopsy
|
B.
|
IgA EMA
|
C.
|
IgA tTGA
|
D.
|
IgA EMA
+ IgA tTGA
|
E.
|
rectal
biopsy
|
Question 8.
Lead-in
Which, if
any, of the following statements are true in relation to the woman due to have
testing for suspected CD?
Option List
A.
|
continue
with a normal diet.
|
B.
|
continue with a normal diet that includes a minimum of
5 gm. gluten daily
|
C.
|
continue with a normal diet that includes a minimum of
10 gm. gluten daily
|
D.
|
follow a strict gluten-free diet for at least 1 month
|
E.
|
follow a strict gluten-free diet for at least 3 months
|
Question 9.
Lead-in
Which of
the following conditions should make consideration of testing for CD sensible?
Option List
A.
|
amenorrhoea
|
B.
|
Down’s syndrome
|
C.
|
epilepsy
|
D.
|
recurrent miscarriage
|
E.
|
Turner’s syndrome
|
F.
|
unexplained infertility
|
Question 10.
Lead-in
How is the
diagnosis of CD confirmed after +ve serological testing?
Option List
A.
|
colonoscopy
|
B.
|
enteroscopy
|
C.
|
gastroscopy
|
D.
|
rectal biopsy
|
E.
|
small
bowel biopsy
|
Question 11.
Lead-in
Which skin
condition is particularly associated with CD?
Option List
A.
|
atopic
eczema
|
B.
|
dermatitis herpetiformis
|
C.
|
dermatitis multiforme
|
D.
|
dermatographia
|
E.
|
psoriasis
|
Question 12.
Lead-in
Which of
the following are likely to be absorbed less well than normally in women with
CD?
Option List
A.
|
carbohydrate
|
B.
|
fat
|
C.
|
folic acid
|
D.
|
protein
|
E.
|
vitamins B12, D & K
|
Question 13.
Lead-in
What is
the appropriate treatment of CD?
Option List
A.
|
antibiotics:
long-term in low-dosage
|
B.
|
azathioprine
|
C.
|
cyclophosphamide
|
D.
|
rectal steroids
|
E.
|
none of the above
|
Question 14.
Lead-in
Which of
the following do not contain gluten?
Option List
A.
|
barley
|
B.
|
oats
|
C.
|
rapeseed oil
|
D.
|
rye
|
E.
|
wheat
|
36. EMQ. Anti-D prophylaxis.
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?
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grateful to Dr Aderemi Omotayo and His super natural spell casting and will not stop publishing his name on the internet just for the good work he has done.
If you need his help, you can email him at Your new email address is aderemi.omtayospellhome@gmail.com or call his phone number +2349058157214 and he will
also help you too. I will be forever grateful to you (Dr Aderemi Omotayo).