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63	Role-play. Cytomegalovirus and pregnancy.
64	Structured discussion. Enhanced recovery.
65	EMQ. Cytomegalovirus.
66	EMQ. Education
67	SBA. Blob and Bagel signs

63. Role-play. Cytomegalovirus and pregnancy.

Candidate’s instructions.

You are a SpR4 and soon to sit the Part 3 MRCOG exam. You are on-call for the labour ward and things are quiet, with two healthy young women in normal labour. You were having a coffee with the on-call team. The FY1 who recently started in the department mentioned that her sister had asked for advice about cytomegalovirus infection and pregnancy. She did not know much about it and has asked where she should look for advice. The consultant replied that this is an ideal opportunity for you to practise a role-play and to deal with her query and explain the essential facts about CMV. Explain what this kind of opportunistic teaching is called in medical-education-speak.

64. Structured discussion. Enhanced Recovery.

Candidate's instructions.

You are a newly-appointed consultant. The Clinical Director has asked you to develop a programme for enhanced recovery for inpatient gynaecological surgery. As a first step, she has asked you to deliver a talk to a unit meeting (all staff can attend) to outline the key features of enhanced recovery. She suspects most of the staff know little about the subject and hopes that your talk will encourage their enthusiastic participation. The examiner will ask you 9 questions pertinent to your talk.

65. Cytomegalovirus  infection in pregnancy.

Abbreviations.

AI:              avidity index.

CMV:         cytomegalovirus.

CNS:          central nervous system.

FGR:          fetal growth restriction.

HIG:           hyperimmunoglobulin.

IUFD:         intrauterine fetal death.

Scenario 1.           

What does the term “cytomegalovirus” mean?

Option list.

A	it is an unusually large virus
B	it is the largest known virus
C	the viral cytoplasm is increased in volume
D	infected cells are enlarged and have enlarged nuclei
E	none of the above

Scenario 2.           

Which of the following terms is used in relation to CMV infected cells?

Option list.

A	almond-eyed
B	apple of my eye
C	cross-eyed
D	doe-eyed
E	owl-eyed

Scenario 3.           

Which family of viruses does CMV belong to?

Option list.

A	Adenoviridae
B	Arachnoviridae
C	Enteroviridae
D	Herpesviridae
E	Poxviridae

Scenario 4.           

What kind of virus is CMV?

Option list.

A	bacteriophage
B	DNA virus
C	RNA virus
D	none of the above

Scenario 5.           

What is the structure of the herpes virus?

Option list.

A	double-stranded DNA core, surrounded by three layers: capsid, tegument and envelope
B	single-stranded DNA core, surrounded by two layers: capsid and envelope
C	double-stranded RNA core, surrounded by three layers: capsid, tegument and envelope
D	single-stranded RNA core, surrounded by two layers: capsid and envelope
E	none of the above

Scenario 6.           

How many herpes viruses have been described?

Option list.

A	>1,000
B	>   500
C	>   250
D	>   100
E	none of the above.

Scenario 7.           

How many herpes viruses are of relevance to human infection?

Option list.

A	8
B	10
C	12
D	14
E	20

Scenario 8.           

Write the list of herpes viruses which affect humans and the conditions they cause?

Option list.

There is none. You have to write your own list.

Scenario 9.           

Where does CMV rank in the list of the most common causes of congenital viral infection?

Option list.

A	1
B	2
C	3
D	4
E	5

Scenario 10.        

Which of the following statements is the most accurate in relation to CMV?

Option list.

A	CMV can lie dormant after 1ry. infection, usually in bone marrow
B	CMV can lie dormant after 1ry. infection, usually in dorsal root ganglia
C	CMV can lie dormant after 1ry. infection, usually in the lungs
D	CMV can lie dormant after 1ry. infection, usually in the salivary glands
E	CMV does not lie dormant after 1ry. infection

Scenario 11.        

Which, if any, of the following statements is true of CMV & pregnancy in the UK?

Option list.

A	approximately 10-20% of women are immune before their 1st. pregnancy
B	approximately 20-30% of women are immune before their 1st. pregnancy
C	approximately 30-50% of women are immune before their 1st. pregnancy
D	approximately 40-60% of women are immune before their 1st. pregnancy
E	none of the above

Scenario 12.        

Which of the following statements is true in relation to vertical transmission?

Option list.

A	it is mainly transplacental
B	it is mainly due to feto-maternal haemorrhage
C	it mainly occurs during labour and delivery
D	it mainly occurs during lactation
E	none of the above

Scenario 13.        

What is the approximate incidence of 1^ry. CMV infection in pregnancy?

Option list.

A	<   1%
B	<   5%
C	<   7.5%
D	< 10%
E	≥ 10%

Scenario 14.        

What is the biggest source of CMV infection for women of reproductive age?

Option list.

A	contaminated food or water
B	blood transfusion
C	infected sexual partner
D	infected small children
E	undercooked meat, particularly pork

Scenario 15.        

What proportion of 1^ry. maternal CMV infection in pregnancy is asymptomatic?

Option list.

A	up to 10%
B	11 – 29%
C	30 – 49%
D	50 – 79%
E	80 – 89%
F	≥ 90%

Scenario 16.        

What is the approximate prevalence of CMV infection in UK neonates?

Option list.

A	0.10- 0.25%
B	0.10- 0.50%
C	0.20- 0.50%
D	0.20- 1.00%
E	0.20- 2.25%

Scenario 17.        

Where does CMV rank in the non-genetic causes of SNHL in children?

Option list.

A	1
B	2
C	3
D	4
E	none of the above

Scenario 18.        

When does vertical transmission carry the greatest risk of inflicting neurological damage on the fetus?

Option list.

A	with 1ry infection during the 1st. trimester
B	with 2ry infection during the 1st. trimester
C	with 1ry infection during the 2nd. trimester
D	with 2ry infection during the 2nd. trimester
E	with 1ry infection during the 3rd. trimester
F	with 2ry infection during the 3rd. trimester
G	with 1ry infection during labour / delivery
H	with 2ry infection during labour / delivery
I	none of the above

Scenario 19.        

What is the risk of vertical transmission after CMV infection in the immediate preconception period?

Option list.

A	< 1%
B	1-5%
C	6-10%
D	11-15%
E	16-20%
F	21-30%

Scenario 20.        

A fetus is infected with CMV at the time of highest risk for neurological damage. What is the approximate upper limit for the risk that the child will have neurological damage?

Option list.

A	up to 1%
B	up to 5%
C	up to 7.5%
D	up to 10%
E	up to 12.5%
F	up to 15%
G	up to 20%
H	none of the above

Scenario 21.        

Approximately what % of cerebral palsy is thought attributable to fetal CMV infection?

Option list.

A	1%
B	5%
C	7.5%
D	10%
E	12.5%
F	15%
G	20%
H	25%

Scenario 22.        

Approximately what % of SNHL is thought attributable to fetal CMV infection?

Option list.

A	1%
B	5%
C	7.5%
D	10%
E	12.5%
F	15%
G	20%
H	25%

Scenario 23.        

Which, if any, of the following statements is true of CMV?

Option list.

A	1ry. infection is followed by life-long latent infection
B	1ry. infection is followed by life-long latent infection in a minority of cases
C	life-long latent infection is characteristic of CMV but not other herpes viruses
D	life-long latent infection only occurs after 2ry. infection
E	none of the above.

Scenario 24.        

How is 1ry. maternal CMV infection best diagnosed?

Option list.

A	by the regional laboratory
B	IgM to IgG conversion
C	presence of IgM with low avidity IgG
D	religious conversion
E	sero-conversion from IgG -ve to IgG +ve

Scenario 25.        

Which, if any, of the following statements is true in relation to ‘avidity’ in CMV infection?

Option list.

A	avidity declines directly with the interval from 1ry infection to the test
B	avidity is an indirect measure of viral load
C	avidity measures the determination of the obstetrician to make a diagnosis
D	avidity measures the enthusiasm of the laboratory for maximising the cost of testing
E	avidity measures the strength of binding of CMV antibody to the virus

Scenario 26.        

Which, if any, of the following statements is true in relation to the ‘avidity index’ in CMV infection?

Option list.

A	the AI is the ratio of free: albumin-bound CMV IgG in maternal serum
B	the AI is the IgG antibody titre in maternal serum
C	the AI is the percentage of IgG that is bound to the antigen
D	the AI is the amount of IgG bound to the antigen expressed as micrograms / gram
E	none of the above

Scenario 27.        

Which, if any, of the following statements is true in relation to the ‘avidity index’ in CMV infection?

Option list.

A	an AI < 30 is indicative of old infection
B	an AI < 30 is indicative of recent 1ry infection
C	an AI < 30 suggests a faulty assay
D	the AI assay used in the NHS is standard across all laboratories
E	none of the above

Scenario 28.        

Which, if any, of the following statements is true in relation to identifying women at greatest risk of having a baby with severe congenital infection?

Option list.

A	a low AI < 18 weeks indicates high risk
B	a high AI < 18 weeks indicates high risk
C	a high IgM titre indicates low risk
D	a high IgG titre indicates high risk
E	none of the above

Scenario 29.        

What is UK policy in relation to routine screening for CMV in pregnancy?

Option list.

A	routine screening was introduced in 2018
B	routine screening is not advocated because of cost
C	routine screening is not advocated because of the lack of an accurate test
D	routine screening is not advocated because of cross-reaction with EBV
E	none of the above

Scenario 30.        

What is UK policy in relation to routine screening of the neonate for CMV?

Option list.

A	routine screening was introduced in 2015
B	routine screening is not advocated because of cost
C	routine screening is not advocated because of the lack of an accurate test
D	routine screening is not advocated because of cross-reaction with EBV
E	none of the above

Scenario 31.        

Pick the true statement from the list below?

Option list.

A	avidity testing is not done on CMV IgM antibodies
B	CMV IgG is a maverick and does not play by the usual rules
C	CMV IgM is a maverick and does not play by the usual rules
D	CMV IgG persists for many years
E	CMV IgM persists for 1 year or more
F	none of the above

Scenario 32.        

A woman has been shown to have had CMV infection in pregnancy. It is decided to check for evidence of fetal infection. What does SIP56 say is the mainstay of diagnosing fetal CMV infection.?

Option list.

A	amniocentesis and PCR for evidence of CMV
B	amniocentesis and electron microscopy for evidence of CMV
C	amniocentesis and light microscopy for evidence of CMV
D	amniocentesis and viral culture
E	MRI
F	ultrasound – abdominal
G	ultrasound - transvaginal

Scenario 33.        

A woman has been shown to have had CMV infection in pregnancy. Which, if any of the following statements best describe the role of MRI scanning in assessing the fetus? This is not a true EMQ as more than one statement may be true.

Option list.

A	it should be offered in conjunction with ultrasound
B	it should be offered if ultrasound examination suggests fetal infection
C	it should be offered if ultrasound examination does not suggest fetal infection
D	it should be offered if there is sufficient funding to pay for it
E	the role of MRI scanning is not yet clear
F	none of the above

Scenario 34.        

A pregnant woman is HIV+ve? Which of the following statements is true?

Option list.

A	the risk of vertical transmission in pregnancy is ↑
B	the risk of vertical transmission in pregnancy is ↓
C	the risk of vertical transmission in pregnancy is the same as in HIV-ve women

Scenario 35.        

A pregnant woman is HIV+ve? Which of the following statements is true?

Option list.

A	her neonate is at ↑ risk of acquiring CMV perinatally
B	her neonate is at ↓ risk of acquiring CMV perinatally
C	her neonate is at normal risk of acquiring CMV perinatally
D	none of the above

Scenario 36.        

A pregnant woman is HIV+ve? Her neonate is +ve for both CMV and HIV. Which of the following statements is true?

Option list.

A	the child has a ↓ risk of HIV progression and ↓ risk of CNS damage from CMV
B	the child has a ↓ risk of HIV progression and ↑ risk of CNS damage from CMV
C	the child has a ↓ risk of HIV progression and normal risk of CNS damage from CMV
D	the child has an ↑ risk of HIV progression and ↓ risk CNS damage from CMV
E	the child has an ↑ risk of HIV progression and ↑ risk CNS damage from CMV
F	the child has an ↑ risk of HIV progression and normal risk of CNS damage from CMV
G	the child has a normal risk of HIV progression and ↓ risk of CNS damage from CMV
H	the child has a normal risk of HIV progression ↑ risk of CNS damage from CMV
I	the child has a normal risk of both HIV progression and CNS damage from CMV

Scenario 37.        

Which of the following treatments in pregnancy is of proven efficacy and safety in reducing the risk of vertical transmission to the fetus?

Option list.

A	acyclovir
B	CMV vaccine
C	ganciclovir
D	HIG
E	valaciclovir
F	none of the above

TOG CPD

These derive from the TOG article by Navti et al. The article is from 2016 and is open-access.

TOG. Volume 18, Issue 4 October 2016 Pages 301–7.

Some of the questions are badly written – I would expect exam questions to be better.

Regarding cytomegalovirus (CMV),

1.     it is a double-stranded RNA herpes virus.                                                             True False

2.     it is the commonest congenital viral infection in the developed world.               True False.

3.     prevalence is most common in social class V.                                                     True False

Regarding CMV morbidity,

4.     it is the leading genetic cause of sensorineural deafness.                              True False

5.     maternal infection occurring in the 3^rd. trimester carries the highest risk to the fetus.

True False

6.     previous infection confers complete future immunity to the mother.                    True False

Regarding feto-maternal transmission of CMV,

7.     there is good evidence to suggest that gestational age has no apparent influence on risk of transmission.                                                                                                               True False

8.     breastfeeding is a route of transmission.                                                             True False

9.     for healthy mature babies, an infection with the CMV through breastmilk does not pose significant danger.                                                                                                 True False

10.   transmission can be reduced by appropriate hand washing after nappy changes and exposure to bodily fluids, avoiding kissing young children on mouth and cheeks and by avoiding sharing food, drinks or utensils with young children.                                   True False

11.   primary infection, reactivation and reinfection with different CMV strains during pregnancy has been shown to lead to congenital CMV.                                True False

Regarding maternal CMV in pregnancy,

12.   diagnosis of maternal CMV based on symptoms is reliable with over 70% of women presenting with classic symptoms.                                                                            True False

13.   viral reactivation is more common in HIV positive pregnant women.                            True False

Regarding diagnosis of CMV infection in pregnancy,

14.   seroconversion of CMV specific immunoglobulin G (IgG) in paired acute and convalescent sera is diagnostic of a new acute infection.                            True False

15.   When prepregnancy status is unknown, detection of immunoglobulin M (IgM)- specific antibody is diagnostic of primary infection.                                                   True False

16.   IgM serology is imprecise for determining primary infection as it has been shown to remain positive for up to a year following acute infection.                        True False

17.   The presence of IgG and IgM CMV antibodies with low CMV antibody avidity is diagnostic of primary infection.                                                                              True False

Concerning congenital CMV infection,

18.   85% are asymptomatic at birth.                                                                              True False

19.   30% of affected infants will develop neurological sequelae.                              True False

20.   15% of infants born to mothers with recurrent CMV infection are overtly symptomatic.

                                                                                                                                                  True False

66. Education.

Option list.

1. brainstorming.
2. brainwashing
3. cream cake circle.
4. Delphi technique.
5. demonstration & practice using clinical model.
6. doughnut round.
7. interactive lecture with EMQs.
8. lecture.
9. 1-minute preceptor method.
10. teaching peers / junior colleagues
11. schema activation.
12. schema refinement.
13. small group discussion.
14. snowballing.
15. snowboarding.
16. true
17. false

Scenario 1.

A woman is admitted with an eclamptic seizure. The acute episode is dealt with and she is put on an appropriate protocol. You wish to use the case to outline key aspects of PET and eclampsia to the two medical students who are on the labour ward with you. Which would be the most appropriate approach?

Scenario 2.

You have been asked to provide a summary of the key aspects of the recent Maternal Mortality Meeting to the annual GP refresher course. There are likely to be 100 attendees. Which would be the most appropriate approach?

Scenario 3.

You have been asked to teach a new trainee the use of the ventouse. Which would be the most appropriate approach?

Scenario 4.

You have been asked to teach a group of medical students about PPH. To your surprise you find that they have good basic knowledge. Which technique will you apply to get the most from the teaching session?

Scenario 5.

Your consultant has asked you to get the unit’s medical students to prepare some questions about breech delivery which they can ask of their peers when they next meet. Which technique will you use?

Scenario 6.

You have been asked to discuss 2ry. amenorrhoea with your unit’s medical students. You are uncertain about the amount of basic physiology and endocrinology they remember from basic science teaching. Which technique will you use?

Scenario 7

The RCOG has asked you to chair a Green-top Guideline development committee. You find that there is very little by way of research evidence to help with the process. The College has assembled a team of consultants with expertise and interest in the subject. Which technique would be best to reach consensus on the various elements of the GTG?

Scenario 8

Which of the listed teaching techniques is least likely to lead to deep learning?

Scenario 9

An interactive lecture with EMQs is the best method of teaching. True or false.

Scenario 10

Only 20% of what is taught in a lecture is retained. True or false.

Scenario 11.

The main role of the teacher is information provision. True or false.

Scenario 12.

The main role of the teacher is to be a role model.  True or false.

67. Blob & bagel signs.

Question 1.          

What do the ‘blob and bagel’ signs relate to?

Option List

A	C. section scar pregnancy
B	corpus luteum
C	interstitial pregnancy
D	ovarian ectopic pregnancy
E	tubal ectopic pregnancy

Question 2.          

Which of the following best fits the term ‘blob sign’?

Option List

A	an obese patient
B	a homogeneous mass
C	an amorphous mass
D	an empty gestational sac
E	an inhomogeneous mass

Question 3.          

Which of the following best fits the term ‘bagel sign’?

Option List

A	an obese patient
B	a homogeneous mass
C	an amorphous mass
D	an empty gestational sac
E	an inhomogeneous mass

Question 4.          

Which of the following best applies to the usefulness of the signs?

Option List

A	advocates say they should be taken as definitive in diagnosis
B	they denote obesity precluding effective transabdominal scanning
C	they reflect habitus, which is already obvious
D	they should not be used as they are pejorative
E	never heard of them, so I don’t give a damn