Tutorial 6th. February 2017

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6 February 2017.

71	Medical statistics. Julie Morris.
72	EMQ. Labour 1
73	SBA. Idiopathic intracranial hypertension in pregnancy

Julie plans to go through 10 sample questions. She has also produced a flowchart summarising how data are categorised. Both of these are on Dropbox. Go to the folder "materials for the tutorials" and then the sub-folder "6th. February 2017". You need to work through the questions before listening to the tutorial and you will need a copy of the flowchart during the tutorial.

Question 72.     EMQ. Labour 1.

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 skin 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.

Questions.

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 now 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. She does not have an epidural anaesthetic. 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?

Question 72.     SBA. Idiopathic intracranial hypertension in pregnancy.

Idiopathic intracranial hypertension.

In addition to the following questions, we will discuss the CPD answers from the TOG article. They are open access, so download and answer them. CPD questions. TOG. Volume 16. 2.

Abbreviations.

CSF:         cerebro-spinal fluid

CT scan:  computed tomography scan

IIH:           idiopathic intracranial hypertension

IIP:           increased intracranial pressure

Scenario 1.

Lead-in

Which  of the following statements is true in relation to IH?

Option List

A.	the aetiology is unknown
B.	is associated with severe pre-eclampsia
C.	is due to obesity
D.	is due to impaired ventricular drainage
E.	is due to increased production of CSF in the thoraco-lumbar spine

Scenario 2

Which of the following statements best fits with the prevalence of IIH in women of childbearing age?

Option List

A.	the female: male ratio is 2: 1
B.	the female: male ratio is 1: 2
C.	the prevalence is about 1 in 100,000 in those of normal weight, rising by a factor of about 20 in the obese
D.	the incidence trebles in pregnancy
E.	the incidence falls to normal in the 6 weeks after delivery

Scenario 3.

Which  is the most common presenting symptom in IIH?

Option List

A.	exophthalmos
B.	headache
C.	papilloedema
D.	seizures
E.	visual disturbance

Scenario 4.

Which of the following are features of the headache associated with IIH?

Features

A.	steady, occipital pain with overlying scalp tenderness & sensitivity
B.	throbbing, retro-orbital pain that may worsen with eye movement
C.	accompanied by photophobia
D.	accompanied by auditory hallucinations
E.	accompanied by visual disturbance

Option List

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

Scenario 5.

Which, if any, of following are found with IIH?

Features

A.	papilloedema
B.	reduced colour vision
C.	reduced visual acuity
D.	palsy of the cranial nerve VI
E.	none of the above

Option List

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

Scenario 6.

Which of the following statements is true

Option List

A.	visual symptoms are directly proportional to the degree of papilloedema
B.	visual symptoms are indirectly proportional to the degree of papilloedema
C.	visual symptoms worsen exponentially with the degree of papilloedema
D.	visual symptoms are independent of the degree of papilloedema
E.	none of the above

Scenario 7.

The features of IIH were described by Dr. X in and subsequently used to create a list of diagnostic criteria by Dr. Smith in 1985.  What was the name of Dr. X?

Option List

A.	Dr. Beano
B.	Dr. Dandy
C.	Dr. Fop
D.	Dr. Fineanddandy
E.	none of the above.

Scenario 8.

What are the diagnostic criteria named eponymously after Dr. X?

There is no option list – add what you know.

Scenario 9.

What are the characteristic features of the CSF?

Features

A.	pressure > 100 mmH2O
B.	pressure > 250 mmH2O
C.	↑ angiotensin
D.	↑ protein
E.	↑ white blood cells

Option List

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

Scenario 10.

What imaging is recommended?

Option List

A.	skull x-ray
B.	CT scan
C.	MR scan
D.	CT scan with MR added in atypical cases
E.	none of the above.

Scenario 11.

Which of the following are described in relation to CT scanning?

Option List

A.	the fetal radiation dose is below the recommended maximum in a maternal head scan
B.	the fetal radiation dose is close to the recommended maximum in a maternal head scan
C.	gadolinium contrast media cross the placenta and have been teratogenic in animal studies
D.	the European Society of Radiology guidelines say that gadolinium should not be used in pregnancy
E.	none of the above.

Scenario 12.

Which of the following are described in relation to IIH?

Option List

F.	papilloedema
G.	severe visual loss in up to 20% of cases
H.	central vision is preserved
I.	enlargement of the blind spot
J.	loss of peripheral field acuity

Scenario 13.

How should visual function be monitored?

Option List

A.	fundoscopy
B.	disc imaging
C.	quantitative serial perimetry
D.	qualitative serial perimetry
E.	radio-isotope retinal mapping

Scenario 14.

Which of the following are accurate in relation to the effect of IIH on pregnancy and pregnancy on IIH?

Option List

A.	TOP should be recommended if there is any evidence of visual loss as this can deteriorate dramatically even with good monitoring
B.	PET is more common
C.	IIH makes pregnancy less common due to pituitary pressure and ↓ secretion of FSH & LH
D.	pregnancy is a risk factor for IIH and visual outcomes are worse
E.	IIH has no averse pregnancy outcomes and TOP is not indicated

Scenario 15.

Which of the following statements are true in relation to management of IIH in pregnancy?

Option List

A.	the management is the same as in the non-pregnant
B.	the aims of management are symptom control and preservation of vision
C.	dietary changes aiding weight loss are important in the overweight
D.	analgesics and diuretics are prescribed
E.	repeated lumbar puncture, CSF shunts and optic nerve sheath fenestration are used.

Scenario 16.

Which of the following statements is most apt regarding the safest mode of delivery?

Option List

A.	Caesarean section is the preferred mode of delivery to prevent cerebellar herniation
B.	MOD should be determined on obstetric grounds in most cases
C.	vaginal delivery is acceptable, but “pushing” should be discouraged
D.	neurological symptoms and patient preference should determine MOD in women with CSF shunts
E.	leave it all to Mother Nature.

Scenario 17.

With regard to acetazolamide, which of the following are true?

Option List

A.	it deduces CSF production by choroid plexus
B.	it has been linked to teratogenesis in animals
C.	is not used for IIH in pregnancy
D.	women who conceive on acetazolamide should be advised to have TOP
E.	it should not be used by women who breastfeed as the concentration in breast milk is high and can have adverse effects on neonatal renal blood flow

Scenario 18.                      

What imaging is recommended in the investigation of suspected IIH?

Option List

F.	skull x-ray
G.	CT scan
H.	MR scan
I.	CT scan with MR added in atypical cases
J.	none of the above.

CPD from TOG Volume 16. Issue 2. April 2014.

Idiopathic intracranial hypertension in pregnancy

Idiopathic intracranial hypertension (IIH),

1.     is a disease of unknown aetiology associated with increased intracranial pressure.

2.     is commonly seen in obese young women.

In making the diagnosis of IIH,

3.     the lumbar CSF opening pressure should be greater than 250 mm of water.

4.     the modified Dandy criteria includes tinnitus and vertigo.

5.     CT or MRI demonstrates normal to small symmetrical ventricles.

In IIH and pregnancy,

6.     termination of pregnancy is recommended in symptomatic women.

7.     there is an increased risk of recurrence in subsequent pregnancies.

8.     visual outcome is the same as that for women with IIH who are not pregnant.

With regard to the treatment of IIH in pregnancy,

9.     diet and weight control play a role in symptom improvement.

10.   acetazolamide is contra indicated in pregnancy.

11.   steroids are reserved for the acute phase only.

Regarding the symptoms of IIH in pregnancy,

12.   there is a direct correlation between severe visual symptoms and the degree of papilloedema.

13.   severe visual loss is a recognised complication of up to 50% of cases.

14.   visual obscuration characteristically lasts for a few minutes to hours.

With regard to IIH,

15.   when it occurs in pregnancy, there is an increased risk of obstetric complications.

16.   the increased in intracranial pressure during labour means caesarean section is the preferred method of delivery.

17.   when it predates pregnancy, it tends to worsen in pregnancy.

18.   most cases in pregnancy present in the second half of gestation.

19.   epidural anaesthesia carries a potential risk of increasing intracranial pressure.

20.   the progestogen only contraceptive is recommended only in those in whom a thrombotic event has been excluded.