Tutorial 9th. January 2017

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I can't stop people placing comments. And it is not easy to remove them, even when they are clearly rubbish, like the ones below. But I am sure that you will have recognised them for what they are!

60	EMQ. Turner’s syndrome
61	EMQ. Cervical smears, colposcopy & referral
62	EMQ. Caesarean section. NICE CG 132

60.         Turner’s syndrome.

This is supposed to be an EMQ, but some of the questions are MCQs with “True” and “False” answers. But it includes everything I think you might be asked about Turner’s.

Abbreviations.

DDH	developmental dysplasia of the hip

Option list 1 is for question 2, option list 2 is for all the others.

Option list 1.

	1 in   500
	1 in 1,000
	1 in 1,500
	1 in 2,000
	1 in 2,500
	1 in 3,000
	1 in 10,000
	1 in 50,000

Option list 2.

	0%
	0.1%
	1 %
	2%
	5%
	10%
	15%
	20%
	30%
	40%
	50%
	60%
	70%
	80%
	90%
	> 90%
	Most common
	2nd. most common
	True
	False
	Answer not on this option list.

Questions.

1.         TS is due to 45XO.                                                                                                            True /False

2.         What is the incidence of TS?                                                                                         

3.         The incidence of TS rises with maternal age?            .                                                True /False

4.         Most cases of TS are due to loss of a paternal chromosome.                                True /False

5.         How common is monosomy X in TS?                         

6.         How common is monosomy Y in TS?                         

7.         What % of miscarriages are due to TS?                     

8.         What % of TS pregnancies miscarry?                         

9.         ↑ NT is a feature of TS                                                                                                    True /False

10.     ↑ NT is more common in foetuses with congenital heart disease                        True /False

11.     Low birth weight is a feature of TS.                                                                               True /False.

12.     If TS is suspected, but the neonate’s karyotype from blood testing is normal, the diagnosis is Noonan’s syndrome.                                                                                                      True /False.

13.     Neonates with TS are at normal risk of DDH.                                                             True /False

14.     Immune hydrops is more common in TS.                                                                   True /False

15.     Cystic hygroma is more common in TS.                                                                       True /False

16.     What is the approximate risk of gonadal malignancy if there is XY mosaicism in TS?   

17.     How common is webbing of the neck in TS?                           

18.     How common is a low occipital hairline in TS?                       

19.     How common is congenital heart disease in TS?     

20.     Dissecting aortic aneurysm is more common in TS.                                                  True /False

21.     How common is lymphoedema in TS?                       

22.     How common is kidney disease in TS?                       

23.     Short stature in TS has been linked to the TS gene.                                                  True /False

24.     What % of adolescents with TS have scoliosis.         .

25.     Inverted nipples are more common in TS.                                                                  True /False

26.     1ry. amenorrhoea occurs in all cases.                                                                         True /False

27.     Adrenarche occurs at a normal time.                                                                          True /False

28.     Cubitus valgus is more common in TS.                                                                        True /False

29.     Cleft palate if a feature of TS.                                                                                        True /False

30.     Micrognathia is a feature of TS.                                                                                    True /False

31.     Abnormalities of teeth and nails are more common in TS.                                     True /False

32.     Otitis media is more common in TS.                                                                                           True /False

33.     Intelligence is usually lower in TS, especially verbal skills.                                       True /False

34.     Women with TS have higher mortality rates than other women.                          True /False

35.     Oestrogen should be started on diagnosis to promote bone growth.                     True /False

36.     Oestrogen-only HRT is appropriate for bone protection.                                        True /False

37.     Women with TS have an ↑ risk of hypertension.                                                     True /False

38.     Women with TS have an ↑ risk of coeliac disease.                                                  True /False

39.     Women with TS have an increased risk of Crohn’s disease and ulcerative colitis.         True /False

40.     Women with TS have an ↑ risk of diabetes                                                                              True /False

41.     Women with TS have an ↑ risk of hyperthyroidism.             True /False                                   True /False

42.     Women with TS have an ↑ risk of deafness.            .                                                True /False

43.     Women with TS have an ↑ risk of osteoporosis.                                                      True /False

44.     Women with TS have similar rates of red-green colour blindness to men.                      True /False

45.     Women with TS have a normal incidence of ptosis.                                                 True /False

46.     Women with TS cannot have children.                                                                        True /False

47.     The “short stature homeobox” (SHOX) gene has been implicated in TS.                    True /False

61.         EMQ. Cervical smears, colposcopy & referral.

Option list.

A.        repeat the test

B.         repeat the test after 6 months

C.         repeat the test at 6 and 12 months

D.        repeat the test at 6 and 12 months and then annually until she has had 10 years’ follow-up followed by repeat tests at the normal intervals for her age

E.         repeat the test after 3 or 5 years according to her age as per routine follow-up

F.         repeat the test after HPV testing

G.        management according to HRHPV triage

H.        repeat the test after giving an appropriate antibiotic

I.           repeat the test after removing her IUCD.

J.          repeat the test after removing the IUCD and giving an appropriate antibiotic

K.         repeat the test after treating the TZ with diathermy

L.          repeat the test after treating the TZ with cryocautery

M.      discharge from follow-up

N.        refer for colposcopy

O.        refer for colposcopy within 2 weeks

P.         refer for colposcopy within 8 weeks

Q.        refer for colposcopy within 12 weeks

R.         refer for colposcopy only if she has other significant signs or symptoms

S.         refer for cone biopsy

T.         refer for fractional curettage

U.        refer for “see and treat” LLETZ

V.        refer to GUM clinic

W.      recommend that she go back to America

X.         there is insufficient information to formulate a management plan

Y.         false

Z.         true

AA.    none of the above

BB.     age 24 years

CC.     age 24.5 years

DD.   age 25 years

Question 1.

At what age is the first invitation to have a smear test sent?

Option list.

A	20 years
B	22 years
C	24 years
D	24.5 years
E	25 years

Question 2.

Which of the following statements is used by the NHSCSP to justify not offering routine screening to younger women?

Option list.

A	most low-grade changes in younger women regress spontaneously
B	most high-grade changes in younger women regress spontaneously
C	HPV induced changes are common in younger women and screening would cause large numbers of unnecessary colposcopy referrals and be prohibitively expensive
D	colposcopic treatments may cause pre-term labour in subsequent pregnancies
E	there is no evidence that screening younger women reduces incidence of cervical cancer or resulting mortality.

Question 3.

How often should women of 30 have routine smear tests?

Option list.

A	every year
B	every 2 years
C	every 3 years
D	every 4 years
E	every 5 years

Question 4.

A woman of 30 years is due to have a routine smear. How long after the previous smear should the invitation be sent?

Option list.

A	34 months
B	36 months
C	58 months
D	60 months
E	none of the above

Question 5.

How often should women of 50 have routine smear tests?

Option list.

A	every year
B	every 2 years
C	every 3 years
D	every 4 years
E	every 5 years

Question 6.

A woman of 50 years is due to have a routine smear. How long after the previous smear should the invitation be sent?

Option list.

A	34 months
B	36 months
C	58 months
D	60 months
E	none of the above

Question 7.

Which, if any, of the following are grounds for continuing smear tests beyond the age of 64?

Option list.

A	no adequate screening test after the age of 50
B	no adequate screening test after the age of 55
C	no adequate screening test after the age of 60
D	patient’s request due to family history of fatal cervical cancer
E	presence of genital warts

Question 8.

Which, if any, of the following are grounds for smear tests in addition to routine tests?

Option list.

A	history of heavy cigarette consumption
B	1st. use of the combined oral contraceptive
C	diagnosis of genital warts involving the cervix
D	new sexual partner
E	multiple sexual partners

Question 9.

Which, if any, of the following are grounds for smear tests in addition to routine tests in the GUM clinic?

Option list.

A	1st. attendance at a GUM clinic
B	any  attendance at a GUM clinic with proven STI
C	diagnosis of genital warts involving the cervix
D	new sexual partner with history of STI
E	multiple sexual partners – simultaneous
F	multiple sexual partners – not simultaneous

Question 10.

Which, if any, of the following are true of cervical cytology as a means of diagnosing STIs?

Option list.

A	cervical cytology can be used to diagnose chlamydial infections
B	cervical cytology can be used to diagnose gonococcal infections
C	cervical cytology can be used to diagnose herpes
D	cervical cytology can be used to diagnose syphilis
E	cervical cytology can be used to diagnose trichomonal infections

Question 11.

Which of the following should be used in the initial investigation of the woman, younger than the age for inclusion in the NHSCSP programme, who presents with a three month history of intermenstrual and postcoital bleeding?

Option list.

A	inspection of the cervix using a speculum
B	inspection of the cervix using a colposcope
C	pregnancy test
D	screening for chlamydia
E	cervical smear

Question 12.

Which, if any, of the following statements are true with regard to HRHPV as primary screening.

Option list.

A	HRHPV is about 10% more sensitive than LBC in detecting borderline or worse changes
B	HRHPV is about 25% more sensitive than LBC in detecting borderline or worse changes
C	HRHPV detects > 70% of CIN2, CIN3 and invasive cancer
D	HRHPV detects > 90% of CIN2, CIN3 and invasive cancer
E	HRHPV is about 6% less specific in detecting borderline or worse changes

Question 13.

Approximately how much of the NHSCSP was covered by the six sentinel sites used to evaluate modern approaches to cervical screening?

Option list.

A	1%
B	5%
C	10%
D	15%
E	20%

Question 14.

Which of the following statements are true in relation to the data obtained from the six sentinel sites?

Option list.

A	16% of women with low-grade dyskaryosis were HRHPV –ve and returned to routine screening
B	26% of women with low-grade dyskaryosis were HRHPV –ve and returned to routine screening
C	45% of women with borderline changes were HRHPV –ve and returned to routine screening
D	65% of women with borderline changes were HRHPV –ve and returned to routine screening
E	colposcopy referral rates increased by > 60%

Question 15.

Which, if any, of the following statements are true in relation to the NHSCSP in the year ending 31 March 2015?

Statements.

A	85% of eligible women were screened in the year up to 31 March 2015
B	72% of eligible women aged 25-49 years were screened
C	78% of eligible women aged 50-64 years were screened
D	4.31 million women were invited for screening & 3.12 million women were tested
E	98% of women should receive their smear reports within 2/52, but only 91% did
F	3.2 million samples were examined by the laboratories
G	198,216 referrals were made to colposcopy, a 0.6% ↓ from the previous year
H	2.5% of smears were inadequate

Question 16.

Which, if any, of the following statements are true in relation to LBC and the traditional cervical smear?

Statements.

A	both involve drying the slide on which the smear is made in air by the person taking the smear
B	the sensitivity of LBC is superior
C	the specificity of LBC is superior
D	inadequate smears ↓ from about 9% with traditional smears to 1-2% with LBC
E	LBC is now the NHSCSP standard for cervical screening
F	HPV testing cannot be done on routine LBC samples

Question 17.

Lead in.

Which, if any, of the following statements are true in relation to inadequate smears?

A	inadequate smears are defined as those showing insufficient squamous cells
B	inadequate smears are defined as those showing inflammatory changes
C	a smear should not be defined as inadequate if there are borderline or dyskaryotic changes
D	a repeat LBC sample should be obtained within 1 month of an initial inadequate sample
E	a repeat LBC sample should be obtained within 2 months of an initial inadequate sample
F	a repeat LBC sample should be obtained after an initial inadequate sample, but not within 3 months
G	referral for colposcopy is required after 2 consecutive inadequate cervical smear reports
H	referral for colposcopy is required after 3 consecutive inadequate cervical smear reports
I	referral for colposcopy is required after 4 consecutive inadequate cervical smear reports
J	the appointment for initial colposcopy after inadequate smears should be within 6/52 of referral
K	the appointment for initial colposcopy after inadequate smears should be within 12/52 of referral
L	referral for colposcopy after inadequate smears is to exclude invasive cancer

Question 18.

A woman with no previous abnormal smears has a routine smear showing an inadequate sample . What management will you suggest?

Question 19.

A woman with no previous abnormal smears has had a smear showing borderline nuclear changes.  What management will you suggest?

Question 20.

A woman with no previous abnormal smears has had a smear showing borderline nuclear changes. Cervical ectopy is noted.  What management will you suggest?

Question 21.

A woman with no previous abnormal smears has had a smear showing borderline cells of endocervical origin. What management will you suggest?

Question 22.

A woman with no previous abnormal smears has had a smear showing inflammatory changes.  What management will you suggest?

Question 23.

A woman with no previous abnormal smears has had a smear showing inflammatory changes and ALOs. What management will you suggest?

Question 24.

A woman with no previous abnormal smears has had a smear showing inflammatory changes. She takes the COC for contraception. What management will you suggest?

Question 25.

A woman with no previous abnormal smears has had a smear showing inflammatory changes. She has a copper IUCD. What management will you suggest?

Question 26.

A woman with no previous abnormal smears has had a smear showing inflammatory changes and ALOs. She has had hysteroscopic sterilisation with ESSURE. What management will you suggest?

Question 27.

A woman with no previous abnormal smears had a smear showing borderline changes. A repeat smear after 6 months was normal. A repeat smear after 3 years showed mild atypia. A repeat smear after 6 months was normal. A recent repeat smear, 3 years after the previous one, showed borderline changes. What management will you suggest?

Question 28.

A woman with no previous abnormal smears has had a smear showing mild dyskaryosis of squamous cells. What management will you suggest?

Question 29.

A woman with no previous abnormal smears has had a smear showing moderate dyskaryosis of squamous cells. What management will you suggest?

Question 30.

A woman with no previous abnormal smears has had a smear showing severe dyskaryosis of squamous cells. What management will you suggest?

Question 31.

A woman with no previous abnormal smears has had a smear suggestive of invasive disease. What management will you suggest?

Question 32.

A woman with no previous abnormal smears has had a smear showing borderline nuclear changes in glandular cells. What management will you suggest?

Question 33.

A woman with no previous abnormal smears has had a smear showing ? glandular neoplasia. What management will you suggest?

Question 34.

A 30-year-old woman with no previous abnormal smears has had a smear showing ? glandular neoplasia. She is nulliparous and would like to have children. Colposcopic appearances suggest high-grade CGIN. What management will you suggest?

Question 35.

A 50-year-old woman with no previous abnormal smears has had a smear showing ? glandular neoplasia. Colposcopic appearances suggest high-grade CGIN. What management will you suggest?

Question 36.

A 50-year-old woman with no previous abnormal smears has had a smear showing ? glandular neoplasia. Colposcopic appearances suggest high-grade CGIN. An appropriate excisional biopsy is taken which shows no abnormality. What management will you suggest?

Question 37.

A woman with no previous abnormal smears has had a smear showing normal endometrial cells. What management will you suggest?

Question 38.

A woman with no previous abnormal smears has had a smear showing atypical endometrial cells. What management will you suggest?

Question 39.

A woman with no previous abnormal smears and no symptoms has had a smear with a normal result. Clinical examination was normal, but contact bleeding was noted when the smear was taken. The Practice Nurse who took the smear phones you for advice about her management. What advice will you give?

Question 40.

An American woman with no previous abnormal smears has been used to having annual smears. She has had a smear with a normal result and requests a repeat in 12 months. What management will you suggest?

Question 41.

A woman with no previous abnormal smears is on renal dialysis and has had a smear with a normal result. What management will you suggest?

Question 42.

Which, if any, of the following statements are true in relation to women who are HIV +ve compared to those who are HIV -ve?

A	there is an increased incidence of false –ve smear reports
B	there is an increased incidence of false +ve smear reports
C	the prevalence of SILs is 10-20%, 10 times higher than for HIV-ve women
D	the prevalence of SILs is 20-40%, 10 times higher than for HIV-ve women
E	HIV +ve women taking HAART have higher rates of abnormal cytology than HIV –ve women
F	HAART may reduce the prevalence of squamous intraepithelial lesions
G	LGD is less likely to regress
H	LGD is more likely to regress
I	HGD responds less well to standard treatments
J	HGD responds better to standard treatments
K	Close co-operation between the HIV medical team and colposcopists / smear takers is essential

Question 43.

A woman recently diagnosed as HIV +ve has had a smear with a normal result. Previous smears have been normal. Which, if any, of the following statements are true?

A	twice yearly smears should be arranged
B	annual smears should be arranged
C	colposcopy should be arranged if resources permit as part of the initial assessment
D	annual colposcopy should be arranged if resources permit
E	ablation of low-grade CIN should be offered as such lesions are more likely to progress than in HIV –ve women
F	surgical removal of the cervix should be offered if high-grade CIN is diagnosed
G	screening should continue until at least the age of 75
H	women with good response to HAART and normal cytology can safely return to routine screening

Question 44.

A woman with no previous abnormal smears has had a smear with a normal result. She smokes 20 cigarettes daily and has a long history of recurrent genital warts. What management will you suggest?

Question 45.

A woman of 70 presents with postmenopausal bleeding. She had smears at the recommended intervals from the age of 22. All were normal. The last was taken at the age of 64. What is your management in relation to taking a smear?

Question 46.

A woman of 55 presents with hot flushes since her periods stopped at the age of 54. She wishes to go on HRT and there are no contraindications. She had smears at the recommended intervals from the age of 25. All were normal. The last was taken two years ago. What is your management in relation to taking a smear?

Question 47.

Which, if any, of the following statements are true about women who have been treated for CIN compared to women who have not been treated?

A	their risk of developing cervical cancer is increased by a factor of 2 – 5 compared to women who have not been treated
B	women should be returned to community-based recall
C	women should have a cervical sample taken for cytology at 6 months, but only if the excision margins were clear. Where the excision margin was, or may have been involved, colposcopy should be done at 6 months
D	if the 6 months cytology is normal, borderline or low-grade and the HRHPV test is –ve, women should return to routine recall based on their age
E	if the 6 months cytology is normal, borderline or low-grade and the HRHPV test is –ve, women should have repeat cytology at 3 years, regardless of their age
F	if the 6 months cytology shows changes worse than low-grade, colposcopy should be done and HRHPV testing is not required
G	if “test of cure” cytology is done in hospital, it should be in a cytology clinic, not the colposcopy clinic

Question 48.

 More than 50% of women who develop cervical cancer have been lost to follow-up. True or false?

Answer. True.

Question 49.

Which of the following statements are true and which false in relation to treatment of CIN?

a.           cone biopsy is linked to ↓risk of recurrence compared to LLETZ.

b.           the Tz must be seen in its entirety if ablative techniques are to be used

c.           excision margins that are not CIN-free ↑ the risk of recurrence, with endocervical margins that are not CIN-free posing a greater risk that similar ectocervical margins.

d.           age > 35 years increases the risk of recurrent disease.

e.           the “see and treat” policy should no longer be used.

f.            excisional treatments should be used in women > 50 years.

d.           follow-up after treatment for CIN should start between 3 & 6 months from the time of treatment.

e.           the initial follow-up examination after treatment for CIN should be with colposcopy plus cytology.

f.            a failure to achieve negative results in the year after treatment means cone biopsy should be done.

g.           a required standard for treatment success is that ≥ 90% of women should have no evidence of dyskaryosis in the year after treatment.

h.           a required standard for treatment success is that there should be ≤ 5% of histologically-confirmed treatment failures by 1 year after treatment.

Question 50

Women who have had normal follow-up results for 2 years after treatment of CIN 1 can revert to the routine recall.

Question 51.

Follow-up should continue with increased frequency for 5 years after treatment of CIN 2 & 3, after which recall at routine intervals is OK if all the follow-up has been normal. True or false?

Question 52.

A woman with LLETZ for CIN3 twelve months ago had a normal smear 6 months later. A smear taken 12 months after treatment is also normal. What management will you suggest?

Question 53.

A woman with LLETZ for CIN3 twelve months ago had a normal smear 6 months later. A smear taken 12 months after treatment shows mild dyskaryosis. What management will you suggest?

Question 54.

A woman on normal recall has hysterectomy for menorrhagia. There is no evidence of CIN on histology. What follow-up would you recommend?

Question 55.

A woman who was not on normal recall has hysterectomy for menorrhagia. There is no evidence of CIN on histology. What follow-up would you recommend?

Question 56.

Women who have had hysterectomy and require follow-up with vault smears cannot be managed within the NHSCSP. True or False?

Question 57.

A woman who was not on normal recall has hysterectomy for menorrhagia. There is evidence of completely excised CIN3 on histology. What follow-up would you recommend?

Question 58.

A woman who was not on normal recall has hysterectomy for menorrhagia. There is evidence of incompletely excised CIN3 on histology. What follow-up would you recommend?

Question 59.

A woman is referred with severe dyskaryosis, but colposcopy is normal. What follow-up should be recommended?

Question 60.

A woman has FIGO stage 1a1 cervical cancer. She wishes to retain her fertility. Which of the following treatments should be offered?

A	brachytherapy
B	cone biopsy
C	cryocautery
D	laser ablation
E	LLETZ
F	radical trachelectomy
G	simple trachelectomy

Question 61.

A woman has local excision for early cervical cancer. What follow-up should be arranged by the NHSCSP?

A	colposcopy and smears six monthly for 1 year, then annually for 9 years
B	colposcopy and smears six monthly for 2 years, then annually for 8 years
C	smears six monthly for 1 year, then annually for 9 years
D	smears six monthly for 2 years, then annually for 8 years
E	smears six monthly for 5 years, then annually for 5 years
F	none of the above

Question 62.

A woman has conservative treatment for early stage cancer of the cervix. What follow-up should be recommended?

Question 63.

Which, if any, of the following statements are true in relation to pregnancy?

A	routine smear tests should be deferred until after delivery
B	colposcopy requires more expertise than in the non-pregnant
C	all smears suggesting CIN should have initial colposcopic assessment in late 1st. or early 2nd. trimester
D	women with low-grade changes who have been referred to colposcopy because of a +ve HPV test can had colposcopy delayed until after delivery
E	if CIN1 is diagnosed, follow-up can be delayed until after delivery
F	“test of cure” appointments after treatment of CIN 2 or 3 can be deferred until after delivery
G	follow-up assessment after treatment of CGIN can be left until after the delivery if the excision margins were disease-free.
H	the risk of haemorrhage after LLETZ is about 25%

62.         EMQ. Caesarean section. NICE CG 132.

Lead-in.

The following scenarios relate to Caesarean section.

Abbreviations.

cART:                           combination anti-retroviral treatment.

CDUS:                          colour Doppler ultrasound scan.

HAART:                       highly active anti-retroviral therapy.

HCV:                            hepatitis C virus.

HSV:                            herpes simplex virus.

MOD:                          mode of delivery.

MPA:                           morbid placental adherence.

MRI:                            magnetic resonance imaging.

MTCT:                         mother-to-child transmission.

NVD:                           normal vaginal delivery.

pCs                              planned Caesarean section.

pvd                              planned vaginal delivery.

PVL:                             plasma viral load.

SROM:                        spontaneous rupture of membranes.

VBAC:                          vaginal birth after Caesarean section.

Option list.

There is none, to make you think!

Scenarios.

1)      MPA is suspected on a routine 20 week scan in a woman who has had two LSCSs. What advice should she be given in relation to the value of colour Doppler US and MRI? 

2)      What advice is given about women who are infected with hepatitis B?

a      a woman is known to have HIV. When should a decision be taken about MOD?

b.     at what gestation should pCs be done as part of management of HIV in pregnancy?

c.      at what gestation should pCs be done in the woman with HIV, if the grounds are obstetric or the woman’s wish, but not part of the management of HIV?

d.     what advice about MOD should be given to a woman with PVL <50 HIV RNA copies/mL at 36 weeks?

e.     what advice about MOD should be given to a woman with PVL of 200 HIV RNA copies/mL at 36 weeks?

f.      what advice about MOD should be given to a woman with PVL of 300 HIV RNA copies/mL at 36 weeks?

g.     what advice about MOD should be given to a woman with PVL of 400 HIV RNA copies/mL at 36 weeks?

h.     what advice about MOD should be given to a woman with PVL of 600 HIV RNA copies/mL at 36 weeks?

i.      a woman with HIV has been advised that normal delivery is recommended. What additional interventions should be offered when she goes into labour?

k.     what is an elite controller?

        

1	member of the staff of Black Rod in the House of Lords
2	crowd marshal at the Members’ Pavilion at Lord’s Cricket Ground.
3	Gentleman Usher at Buckingham Palace party
4	one of the anti-retroviral drugs that are essential components of HAART.
5	individual who is infected with HIV but maintains low viral and healthy CD4 counts long-term with ART.
6	individual who is infected with HIV but maintains low viral and healthy CD4 counts long-term without ART.

l.      a woman is taking zidovudine monotherapy. Her PVL is <50 HIV RNA copies/mL at 36 weeks? What advice would you give re MOD?

m.    a woman is taking zidovudine monotherapy. Her PVL is 200 HIV RNA copies/mL at 36 weeks? What advice would you give re MOD?

n.     a woman is taking zidovudine monotherapy. Her PVL is 500 HIV RNA copies/mL at 36 weeks? What advice would you give re MOD?

o.     a woman is an elite controller. What advice will you give re MOD?

3)      What advice is given about women who are infected with hepatitis C

4)      What advice is given about women who are infected with HIV?

5)      What advice is given about women who are infected with HIV + hepatitis B?

6)      What advice is given about women who are infected with HIV + hepatitis C

7)      A woman with HIV takes HAART and has a PVL < 50 copies per ml. She wishes Caesarean section for non-obstetric reasons. She has been counselled and Caesarean section has been agreed. At what gestation should it be done?

8)      What advice should be given to the woman with HSV infection in pregnancy?

9)      What is the risk of MTCT after primary HSV infection in the 3^rd. trimester?

10)   A woman presents with genital herpes at 36 weeks’ gestation in her first pregnancy. As far as she is aware, this is her first episode of HSV infection. What is the chance that it is a recurrent infection?

11)   A woman presents with genital herpes at 36 weeks’ gestation in her third pregnancy. As far as she is aware, this is her first episode of HSV infection. What is the chance that it is a recurrent infection?

12)   A woman presents with genital herpes at 36 weeks’ gestation in her first pregnancy. As far as she is aware, this is her first episode of HSV infection. What test should be done to clarify whether it is a 1ry. or recurrent infection?

13)   A woman presents with genital herpes at 36 weeks’ gestation in her first pregnancy. As far as she is aware, this is her first episode of HSV infection. Swabs are taken from the skin lesions and blood is taken for HSV type-specific antibodies. She goes into labour at 38 weeks before the results of the HSV type specific antibody tests are available. What advice should be given re mode of delivery?

14)   A woman presents with genital herpes at 36 weeks’ gestation in her first pregnancy. As far as she is aware, this is her first episode of HSV infection. Swabs are taken from the skin lesions and blood is taken for HSV type-specific antibodies and confirm 1^ry.  infection.  She goes into labour with intact membranes at 38 weeks and declines Cs. What action should be taken with regard to anti-viral treatment?

15)   A woman presents in labour at 38 week’s gestation, 2 weeks after a 1^ry. infection with genital HSV. She declines Caesarean section, but opts for antiviral treatment for her and the baby. Which drug should be considered and in what doses?

16)   A woman presents in labour at 38 week’s gestation, 2 weeks after a 1^ry. infection with genital HSV. She had SROM 6 hours before.

17)   A woman presents in early labour at 38 weeks’ gestation. She has a history or recurrent genital HSV. She has a typical herpetic blister on the vulva. What risk of neonatal infection will you quote in the discussion?

18)   A woman presents in labour at term with lesions and a history that are typical of 1^ry. genital HSV infection. Which invasive procedures, if any, should be avoided?

19)   A woman with a history of recurrent genital herpes presents in labour at 40 weeks with a typical vulval herpetic blister. Which invasive procedure, if any, should be avoided?

20)   A baby is born by Caesarean section after maternal 1^ry. genital herpes one month before. Which, if any, of the following are appropriate?

Option list.

A.      liaise with the neonatal unit

B.      normal postnatal care of the baby with examination at 24 hours, then discharge if well and feeding is established.

C.      swabs of skin, conjunctiva, oropharynx and rectum for HSV PCR

D.      lumbar puncture for evidence of HSV

E.       parents to be educated re good hand hygiene

F.       i.v. acyclovir, 20 mg/kg 8 hourly until active infection is ruled out.

G.      strict infection control procedures should be put in place for both mother and baby.

H.      breastfeeding should be discouraged because of the presence of HSV in breast milk.

I.        parents advised to seek medical help if they have concerns, in particular, skin, eye or mucous membrane lesions, lethargy, irritability or poor feeding

21)  A baby is born normally after maternal 1^ry. genital herpes one month before. The mother had declined C section and intends to breast feed. Which, if any, of the following are appropriate? Option list.

J.        liaise with the neonatal unit

K.      normal postnatal care of the baby with examination at 24 hours, then discharge if well and feeding is established.

L.       swabs of skin, conjunctiva, oropharynx and rectum for HSV PCR

M.   lumbar puncture for evidence of HSV

N.     parents to be educated re good hand hygiene

O.     i.v. acyclovir, 20 mg/kg 8 hourly until active infection is ruled out.

P.      strict infection control procedures should be put in place for both mother and baby.

Q.     breastfeeding should be discouraged because of the presence of HSV in breast milk.

R.      parents advised to seek medical help if they have concerns, in particular, skin, eye or mucous membrane lesions, lethargy, irritability or poor feeding,

S.       involvement of child protection service.

22)  A baby is born by Caesarean section after maternal 1^ry. genital herpes one month before. Which, if any, of the following are appropriate?

Option list.

T.      liaise with the neonatal unit

U.     normal postnatal care of the baby with examination at 24 hours, then discharge if well and feeding is established.

V.      swabs of skin, conjunctiva, oropharynx and rectum for HSV PCR

W.   lumbar puncture for evidence of HSV

X.      parents to be educated re good hand hygiene

Y.      i.v. acyclovir, 20 mg/kg 8 hourly until active infection is ruled out.

Z.       strict infection control procedures should be put in place for both mother and baby.

AA. breastfeeding should be discouraged because of the presence of HSV in breast milk.

BB.  parents advised to seek medical help if they have concerns, in particular, skin, eye or mucous membrane lesions, lethargy, irritability or poor feeding

23)   What proportion of neonatal HSV infection is thought to be due to infection after birth?

24)   What steps should be taken to reduce the risk of neonatal HSV infection?

25)   A primigravida attends for booking. She requests Caesarean section. There are no clinical grounds. Outline your management.   

26)   A woman with BMI > 50 should be offered Caesarean section. True/ False.

27)   When should prophylactic antibiotics in relation to the timing of the operation?

28)   A woman has had her 3^rd. Caesarean section. She wants to know the advice you would give re the risks of subsequent vaginal delivery.

29)   What are the key aspects of induction of general anaesthesia for unplanned Cs?

30)   What should be done about thromboprophylaxis for women having Cs?

31)   Which abdominal incision is recommended for Cs?

A	William Fletcher Shaw
B	Victor Bonney
C	Ignaz Semmelweis
D	Joel-Cohen
E	Pfannenstiel

32)   Separate scalpels should be used for the skin and subsequent incisions to reduce infection. True/False.

33)   If the lower segment is well-formed, blunt dissection should be used to extend the initial uterine incision. True / False.

34)   What is the risk of fetal laceration?

A	0.1%
B	0.5%
C	1%
D	2%
E	5%

35)   Routine use of forceps to deliver the head is acceptable practice. True / False.

36)   I.v. syntometrine is the recommended oxytocic. True / False.

37)   Which of the following statements reflects the advice in CG132 about delivery of the placenta.

A	Crede’s manoeuvre is the recommended routine method for DOP
B	Leopold’s  manoeuvre is the recommended routine method for DOP
C	Steptoe’s manoeuvre is the recommended routine method for DOP
D	CCT is the recommended routine method for DOP
E	MROP manoeuvre is the recommended routine method for DOP

38)   Co-amoxiclav is on the list of recommended antibiotics in CG132 for routine prophylaxis at Cs. True / False.

39)   Repair of the uterus is best done with the uterus exteriorised. True / False.

40)   CG132 advises that single or double-layer closure of the lower segment are equivalent and closure is a matter of choice for the surgeon. True / False.

41)   CG132 advises closure of both visceral and parietal peritoneum. True / False.

42)   Mass closure with a non-absorbable suture should be used for closure of mid-line incisions. True / False.

43)   What is the suggested threshold for closure of the subcutaneous fat?

	Subcutaneous fat thickness
A	1 cm.
B	2 cm.
C	3 cm.
D	4 cm.
E	≥ 5 cm.

44)   Liberal use of subcutaneous drains is encouraged to reduce wound infection rates. True / False.

45)   When choosing an antibiotic for prophylactic use at Cs, what infections should particularly be considered?

46)   Staff should be silent immediately before and after the birth of the baby as hearing the mother’s voice as the first ex-utero experience encourages bonding. True / False.