49
|
EMQ. Appendicitis & pregnancy
|
50
|
SBA. Fetal origins of adult disease
|
51
|
EMQ. Drugs in O&G 1
|
52
|
EMQ. Androgen insensitivity syndrome
|
Question 49. Appendicitis in pregnancy (AIP)
Abbreviations.
AIP
|
Appendicitis
in pregnancy
|
CRP
|
C
reactive protein
|
CT
|
computed
tomography, also known as computerised tomography
|
RLQP
|
right
lower quadrant pain
|
RUQP
|
right upper
quadrant pain
|
Question 1.
Lead-in. What is the approximate incidence of appendicitis in pregnancy?
Option List
A.
|
1 in 500
|
B.
|
1 in 1,000
|
C.
|
1 in 2,000
|
D.
|
1 in 5,000
|
E.
|
1 in 10,000
|
Question 2.
Lead-in. When is appendicitis in pregnancy most common?
Option List
A.
|
first
trimester
|
B.
|
second trimester
|
C.
|
trimester
|
D.
|
1st. and 2nd. stages of labour
|
E.
|
in the hours after the 3rd. stage of labour
|
F.
|
during the puerperium
|
Question 3.
Lead-in. What eponymous title is given to the surface marker for the appendix?
Option List
A.
|
McBarney’s
point
|
B.
|
MacBurney’s point
|
C.
|
McBurney’s point
|
D.
|
MacBorney’s point
|
E.
|
McBorney’s point
|
Question 4.
Lead-in. Where is the point referred to in the above question?
Option List
A.
|
1/3 of
the way along the line joining the anterior superior iliac spine and
umbilicus
|
B.
|
1/2 of the way along the line joining the anterior
superior iliac spine and umbilicus
|
C.
|
2/3 of the way along the line joining the anterior
superior iliac spine and umbilicus
|
D.
|
1/3 of the way along the line joining the left and
right anterior superior iliac spines
|
E.
|
1/2 of the way along the line joining the left and
right anterior superior iliac spines
|
Question 5.
Lead-in.
Which, if
any, of the following statements are true about the person after whom the point
in the above questions is named?
Statements
A.
|
he spent
2 years as a postgraduate working in Berlin, London, Paris and Vienna
|
B.
|
he was
Professor of surgery at the Roosevelt hospital, New York from 1889 to 1894
|
C.
|
he presented his classical paper on appendicitis to the
NY Surgical Society in 1889
|
D.
|
he was a transvestite
|
E.
|
he died of a heart attack while on a hunting trip
|
Question 6.
Lead-in.
Pick the
best option from the list below in relation to right lower quadrant pain in appendicitis
in the pregnant and non-pregnant.
Option List
A
|
comparative figures for the pregnant and non-pregnant
are unknown due to the rarity of appendicitis in pregnancy
|
B
|
RLQP is
as common in the pregnant as in the non-pregnant
|
C
|
RLQP is
less common in the pregnant
|
D
|
RLQP is more common in the pregnant
|
E
|
RLQP is rare in pregnancy
|
Question 7.
Lead-in.
Pick the
best option from the list below in relation to right upper quadrant pain in appendicitis
in the pregnant and non-pregnant.
Option List
A
|
comparative figures for the pregnant and non-pregnant
are unknown due to the rarity of appendicitis in pregnancy
|
B
|
RUQP is
½ as common in the pregnant as in the non-pregnant
|
C
|
RUQP is
as common in the pregnant as in the non-pregnant
|
D
|
RUQP is
twice as common in the pregnant as in the non-pregnant
|
E
|
RUQP is
four times as common in the pregnant as in the non-pregnant
|
Question 8.
Lead-in.
Pick the
best option from the list below in relation to nausea in appendicitis in the
pregnant and non-pregnant.
Option List
A
|
comparative figures for the pregnant and non-pregnant
are unknown due to the rarity of appendicitis in pregnancy
|
B
|
nausea
is as common in the pregnant as in the non-pregnant
|
C
|
nausea
is less common in the pregnant
|
D
|
nausea is more common in the pregnant
|
E
|
nausea is rare in pregnancy
|
Question 9.
Lead-in.
Which
condition did CMACE say should be excluded in women presenting acutely with
gastrointestinal symptoms?
Option List
A
|
aortic dissection
|
B
|
appendicitis
|
C
|
Caesarean
section scar pregnancy
|
D
|
ectopic pregnancy
|
E
|
pancreatitis
|
F
|
ovarian torsion
|
Question 10.
Lead-in.
Pick the
best option from the list below in relation to abdominal guarding in appendicitis
in the pregnant and non-pregnant.
Option List
A
|
comparative figures for the pregnant and non-pregnant
are unknown due to the rarity of appendicitis in pregnancy
|
B
|
abdominal
guarding is as common in the pregnant as in the non-pregnant
|
C
|
abdominal
guarding is less common in the pregnant
|
D
|
abdominal
guarding is more common in the pregnant
|
E
|
abdominal
guarding is rare in pregnancy
|
Question 11.
Lead-in.
Pick the
best option from the list below in relation to rebound tenderness in appendicitis in the pregnant and
non-pregnant.
Option List
A
|
comparative figures for the pregnant and non-pregnant
are unknown due to the rarity of appendicitis in pregnancy
|
B
|
rebound tenderness is as common in the pregnant as in
the non-pregnant
|
C
|
rebound tenderness is less common in the pregnant
|
D
|
rebound tenderness is more common in the pregnant
|
E
|
rebound tenderness is rare in pregnancy
|
Question 12.
Lead-in.
Pick the
best option from the list below in relation to fever in appendicitis in the
pregnant and non-pregnant.
Option List
A
|
comparative figures for the pregnant and non-pregnant
are unknown due to the rarity of appendicitis in pregnancy
|
B
|
fever is
as common in the pregnant as in the non-pregnant
|
C
|
fever is
less common in the pregnant
|
D
|
fever
is more common in the pregnant
|
E
|
fever
is rare in pregnancy
|
Question 13.
Lead-in. How useful is the finding of leucocytosis in making the diagnosis of
AIP?
Option List
A.
|
sine qua
non
|
B.
|
very useful
|
C.
|
not very useful
|
D.
|
I don’t know
|
Question 14. How useful is the finding of a raised CRP level in the diagnosis of AIP?
Option List
A.
|
sine qua
non
|
B.
|
very useful
|
C.
|
not very useful
|
D.
|
I don’t know
|
Question 15. Lead-in
What are
the ultrasound features of appendicitis?
Option List
A
|
appendix
with diameter > 0.6 mm.
|
B
|
appendix with diameter > 1 cm.
|
C
|
blind-ending tubular structure
|
D
|
non-compressible
tubular structure
|
E
|
none of the above
|
Question 16.
Lead-in. What figures do W&M give for sensitivity & specificity for US
diagnosis of appendicitis?
Option List
Sensitivity
|
Specificity
|
|
A
|
≥65%
|
≥80%
|
B
|
≥75%
|
≥85%
|
C
|
≥86%
|
≥97%
|
D
|
≥91%
|
≥98%
|
E
|
≥95%
|
≥95%
|
Question 17.
Lead-in. Which, if any, of the following statements are true about CT scanning
for the diagnosis of AIP?
Option List
A
|
CT scanning
has sensitivity > 85% and specificity >95%
|
B
|
CT scanning exposes mother and fetus to radiation doses
of little concern
|
C
|
CT scanning has replaced ultrasound scanning for AIP
|
D
|
CT scanning is not of proven value after inconclusive
ultrasound scanning
|
E
|
CT scanning is of proven value and most useful after inconclusive ultrasound scanning
|
Question 18.
Lead-in. Which, if any, of the following statements are true about MRI scanning
for the diagnosis of AIP?
Option List
A
|
MRI
scanning has sensitivity > 90% and specificity >97%
|
B
|
MRI scanning exposes mother and fetus to radiation
doses of little concern
|
C
|
MRI scanning has replaced ultrasound scanning for AIP
|
D
|
MRI scanning is not of proven value after inconclusive
ultrasound scanning
|
E
|
MRI scanning is of proven value and most useful after inconclusive ultrasound scanning
|
Question 19
Lead-in. Which, if any, of the following statements are true about the
complications of AIP?
Option List
A
|
fetal
loss rate in uncomplicated AIP is about 1.5%
|
B
|
fetal loss rate in AIP complicated by peritonitis is
about 6%
|
C
|
fetal
loss rate in AIP complicated by perforation of the appendix is up to 36%
|
D
|
pre-term delivery rates increase in AIP complicated by
perforation of the appendix
|
E
|
a low level of suspicion should apply to the diagnosis
of AIP in relation to surgical intervention
|
Question 20
Lead-in. Which, if any, of the following statements are true about surgery for AIP?
Option List
A
|
laparotomy
should be done through a grid-iron incision with the mid-point the surface
marker for the appendix in the right iliac fossa
|
B
|
laparotomy should be done through a right paramedian
incision starting at the level of the umbilicus
|
C
|
about
35% of laparotomies show no evidence of appendicitis
|
D
|
the appendix should be removed even if it looks normal
|
E
|
antibiotic therapy is an alternative to surgery in
early cases of AIP
|
Question 21
Lead-in. Which, if any, of the following statements are true about surgery for AIP?
Option List
A
|
laparotomy
should be done through a grid-iron incision with the mid-point the surface
marker for the appendix in the right iliac fossa
|
B
|
laparotomy should be done through a right paramedian
incision starting at the level of the umbilicus
|
C
|
about
35% of laparotomies show no evidence of appendicitis
|
D
|
the appendix should be removed even if it looks normal
|
E
|
antibiotic therapy is an alternative to surgery in
early cases of acute AIP
|
Question 22
Lead-in. Which, if any, of the following statements are true about surgery for AIP?
Option List
A
|
laparoscopic
appendicectomy is an acceptable alternative to laparotomy, but only in the 1st.
trimester
|
B
|
laparoscopic appendicectomy is an acceptable
alternative to laparotomy, but only in the 1st. & 2nd.
trimesters
|
C
|
laparoscopic appendicectomy is an acceptable
alternative to laparotomy, at all gestations
|
D
|
there is evidence that laparoscopic appendicectomy is
associated with doubling of the rate of fetal loss
|
TOG has the following questions. Make sure you have read
the article: It is now open-access.
“Appendicitis in
pregnancy: how to manage and whether to deliver.” Polly Weston & Paul
Moroz. TOG. April 2015. Vol 17, Issue 2; Pages
105–10. Make sure you can answer the questions, which are open-access.
Appendicitis is a likely
diagnosis in pregnancy when,
1. ultrasound
shows a non-compressible blind-ending tube in the right iliac fossa measuring
10 mm in diameter. T/F
2. a
patient presents with right-sided abdominal pain, constipation and malaise. T/F
In the diagnosis of appendicitis in pregnancy,
3. ultrasound
is the best method for imaging in a morbidly obese patient. T/F
4. MRI
has the greatest specificity of all imaging modalities. T/F
With regard to the management of a pregnant patient with
appendicitis,
5. it
should be operative if the diagnosis is certain. T/F
6. it
should primarily aim to reduce any delay in surgical intervention. T/F
7. it
should not involve appendicectomy if the appendix appears normal at the time of
surgery. T/F
8. it
should include delivery of the fetus regardless of gestation if the patient is critically
ill. T/F
9. some
cases may be treated with antibiotics alone. T/F
General anaesthesia for pregnant women undergoing
appendicetomy,
10. carries
an approximately 25-fold increased risk of complications than regional
anaesthesia. T/F
11. has
temporary effects on the fetus as all induction and maintenance agents cross the
placenta. T/F
12. has
a uterotonic effect. T/F
Surgery for appendicetomy in pregnancy,
13. increases
the rate of miscarriage. T/F
14. has
the lowest risk to the fetus when performed in the second trimester. T/F
15. should
be delayed until antenatal corticosteroids are given (in the absence of severe
maternal
sepsis) if the gestation is critical. T/F
Concerning acute appendicitis in pregnancy,
16. it
is the most common cause of acute surgical abdomen. T/F
17. it
most commonly occurs in the first trimester. T/F
18. it
has a fetal loss rate exceeding 50% if the appendix perforates. T/F
With regard to imaging as an investigation for appendicitis
in pregnancy,
19. the
primary goal is to rule out differential diagnoses. T/F
20. the
secondary goal is to reduce the negative appendicectomy rate. T/F
Question 50. Fetal origins of adult disease.
Abbreviations.
ADHD: attention-deficit,
hyperactivity disorder
Lead in.
These
questions relate to disease in adults resulting from events during fetal,
infant and child development.
Scenario 1.
What
eponymous title is given to the concept that adverse intra-uterine conditions
predispose to the development of disease in adulthood?
Option List
F.
|
the Barker hypothesis
|
G.
|
the Baker’s dozen
|
H.
|
the Broadbank theory
|
I.
|
PIPAD: Placental Insufficiency Programmes Adult Disease
|
J.
|
SIMCARD: Stop In-utero Malnutrition to Conquer
Adult-resulting Disease
|
Scenario 2.
Which
other term is used for the concept that adverse intra-uterine conditions
predispose to the development of disease in adulthood?
Option List
A.
|
FDAD: fetal determination of adult disease
|
B.
|
FIAD: fetal
influences on adult disease
|
C.
|
FIDAD: fetal and infancy determinants of adult disease
|
D.
|
FIGO: fetal influences
on genomic outcomes
|
E.
|
FP: fetal
programming
|
Scenario 3.
Which of
the following is thought to increase the risk of adult disease?
Option List
A.
|
low birthweight
|
B.
|
low birthweight followed by poor weight gain in infancy
and childhood
|
C.
|
low birthweight followed by poor weight gain in infancy
but above-average weight gain in childhood
|
D.
|
above-average birthweight
|
E.
|
above-average birthweight followed by poor weight gain
in infancy but above-average weight gain in childhood
|
F.
|
above-average birthweight followed by above-average
weight gain in infancy and childhood
|
Scenario 4.
Which
adult diseases are generally believed to be more likely in relation to adverse
influences on the fetus, infant and child.
Diseases.
A.
|
asthma
|
B.
|
chronic
bronchitis
|
C.
|
coronary
heart disease
|
D.
|
diabetes
type I
|
E.
|
diabetes
type 2
|
F.
|
hypertension
|
G.
|
Mendelson’s
syndrome
|
Option List
A.
|
A + B + C + D
|
B.
|
A + B + C + E
|
C.
|
A + B + C + E + F + G
|
D.
|
B + C + E + F + G
|
E.
|
C + E + F
|
Scenario 5.
What adult
condition has been linked to raised maternal c-reactive protein levels?
Option List
A.
|
asthma
|
B.
|
ADHD
|
C.
|
autism
|
D.
|
inflammatory bowel disease
|
E.
|
schizophrenia
|
Question 51. Drugs in
O&G 1.
Lead-in. The following scenarios relate to drugs
& hypertension in pregnancy.
Pick one option from the option list. Each option can be
used once, more than once or not at all.
Abbreviations.
ACE: angiotensin-converting
enzyme
ACEI: angiotensin-converting enzyme
inhibitor
ARA: angiotensin II receptor antagonist
HG: hyperemesis gravidarum
IUGR: intra-uterine growth retardation
LDA: low-dose aspirin
MAOI: monoamine oxidase inhibitor
Option list.
a)
False.
b)
True.
c)
5
d)
10
e)
15
f)
18
g)
20
h)
24
i)
contraindicated in the
months before pregnancy
j)
contraindicated in the
1st. trimester
k)
contraindicated in the
2nd. trimester
l)
contraindicated in the
3rd. trimester
m) contraindicated in all trimesters
n)
not contraindicated in
pregnancy
o)
contraindicated in
breastfeeding
p)
not contraindicated in
breastfeeding
q)
an acute, severe
illness like rheumatoid arthritis
r)
an acute, severe
illness with encephalopathy and acute fatty liver
s)
an acute, severe
illness with gastro-intestinal tract bleeding
t) there is
insufficient information to be able to provide advice
Scenario 1.
When are ACE inhibitors
contraindicated in pregnancy?
Scenario 2.
When are ARAs contraindicated
in pregnancy?
Scenario 3.
Can St. John’s Wort (SJW) be
used in pregnancy?
Scenario 4.
Methyldopa is an acceptable
option for the treatment of gestational hypertension. True / False.
Scenario 5.
Spironolactone is
contraindicated in pregnancy. True/False
Scenario 6.
Furosemide is an acceptable
option in the management of gestational hypertension. True / False.
Scenario 7.
When are thiazide diuretics
contraindicated in pregnancy?
Scenario 8.
Salbutamol is contraindicated
for the management of premature labour. True / False.
Scenario 9.
Ergometrine is an integral part
of active management of the 3rd. stage. True / False.
Scenario 10.
When is aspirin contraindicated
in pregnancy & the puerperium?
Scenario 11.
When are NSAID’s contraindicated
in pregnancy and why?
Scenario 12.
Pethidine: adverse neonatal
effects are most likely if the drug is administered in the six hours before
birth. True / False.
Scenario 13.
Pethidine: what is the
half-life in the mature neonate?
Scenario 14.
Pethidine is contraindicated in those taking MOAIs or who
have taken them in the previous 2 months.
Scenario 15.
Pethidine is relatively
contra-indicated when there is significant blood loss. True / False.
Scenario 16.
Pethidine has greater analgesic
effect in labour than Diamorphine. True / False.
Scenario 17.
What
is Reye’s syndrome and which family of drugs is particularly linked?
Scenario 18.
What
is “torsades de pointes” and when is it of importance in the management of HG?
Question 52. Topic. Androgen insensitivity syndrome.
Abbreviations.
AIS: androgen
insensitivity syndrome
Question 1.
Lead-in. What is the estimated prevalence of AIS?
Option List
A.
|
2-5 per
100,000 boys at birth
|
B.
|
5-10 per 100,000 girls at birth
|
C.
|
2-5 per 100,000 genetic males at birth
|
D.
|
5-10 per 100,000 genetic females at birth
|
E.
|
none of the above.
|
Question 2.
Lead-in
Which of
the following sub-types of AIS do not exist?
Sub-types
1.
|
complete
AIS
|
2.
|
incomplete AIS
|
3.
|
mild AIS
|
4.
|
partial AIS
|
5.
|
total AIS
|
Option List
A.
|
1
|
B.
|
2
|
C.
|
3
|
D.
|
4
|
E.
|
5
|
F.
|
1 + 3
|
G.
|
2 + 3
|
H.
|
2 + 5
|
I.
|
3 + 5
|
J.
|
4 + 5
|
Question 3.
Lead-in
How common
is partial AIS?
Option List
A.
|
at least
as common as complete AIS
|
B.
|
at least as common as total AIS
|
C.
|
less common than mild AIS
|
D.
|
as common as incomplete AIS
|
E.
|
none of the above.
|
Question 4.
Lead-in
How common
is incomplete AIS?
Option List
A.
|
at least
as common as complete AIS
|
B.
|
at least as common as total AIS
|
C.
|
less common than mild AIS
|
D.
|
as common as partial AIS
|
E.
|
none of the above.
|
Question 5.
Lead-in
How common
is mild AIS?
Option List
A.
|
at least
as common as complete AIS
|
B.
|
at least
as common as total AIS
|
C.
|
less
common than complete AIS
|
D.
|
as
common as partial AIS
|
E.
|
none of
the above.
|
Question 6.
Lead-in
No more
prevalence!!
What is
the mode of inheritance of AIS?
Option List
A.
|
autosomal
dominant
|
B.
|
autosomal
recessive
|
C.
|
X-linked
dominant
|
D.
|
X-linked
recessive
|
E.
|
mitochondrial
|
Question 7.
Lead-in
What
proportion of AIS is due to new mutations?
Option List
A.
|
0%
|
B.
|
1 – 20%
|
C.
|
21 – 40%
|
D.
|
41-60%
|
E.
|
61-80%
|
Question 8.
Lead-in
Which gene
is involved in AIS?
Option List
A.
|
androgen
receptor gene
|
B.
|
aromatase receptor gene
|
C.
|
androstenedione gene
|
D.
|
oestrogen receptor gene
|
E.
|
none of the above
|
Question 9.
Lead-in
How many
mutations have been described of the gene which is involved in AIS?
Option List
A.
|
0-10
|
B.
|
11-100
|
C.
|
101-200
|
D.
|
201-300
|
E.
|
>300
|
Question 10.
Lead-in
Which is
the most common clinical presentation in AIS?
Option List
A.
|
ambiguous
genitalia
|
B.
|
precocious
puberty
|
C.
|
premature
menopause
|
D.
|
primary amenorrhoea
|
E.
|
secondary
amenorrhoea
|
Question 11.
Lead-in
Which of
the following are more common in AIS?
Option List
A.
|
anlagen
|
B.
|
coarctation of the aorta
|
C.
|
“coast of Maine” pigmentation pattern
|
D.
|
renal tract anomalies
|
E.
|
none of the above.
|
Question 12.
Lead-in
A woman of
20 is found to have AIS. She has a pre-pubertal sister. What is the chance that
the sister also has AIS, assuming that the condition is not due to a new
mutation in the elder sister?
Option List
A.
|
1 in 1
|
B.
|
1 in 2
|
C.
|
1 in 3
|
D.
|
1 in 4
|
E.
|
1 in 16
|
Question 13.
Lead-in
What is
the risk of the gonads becoming malignant in AIS?
Option List
A.
|
10%
|
B.
|
20%
|
C.
|
30%
|
D.
|
> 30%
|
E.
|
accurate risk not known
|
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