Thursday 31 December 2020

Tutorial 31 December 2020

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52

EMQ. Anti-D.

53

EMQ. Tranexamic acid.

54

Structured conversation. Apgar score.

55

SBA. McCune-Albright syndrome

56

EMQ. Uterine inversion.

 

52.   EMQ. Anti-D.

Abbreviations.

cffDNA:      cell-free, fetal DNA.

DAT:           direct anti-globulin test.

FDIU:          fetal death in utero.

HDFN:        haemolytic disease of the fetus and newborn.

Ig:               immunoglobulin.

ICS:             intra-operative cell salvage.

i.m:             intra-muscular

NIFBG:       non-invasive fetal blood grouping

NIPT:          non-invasive prenatal testing

RAADP:      routine antenatal anti-D prophylaxis.

RBC:           red blood cells.

RhDAI:       Rhesus D alloimmunisation.

s.c:              sub-cutaneous.

TOP:           termination of pregnancy.

Scenarios.

There is no option list for many questions to force good technique and save me lots of typing!

Question 1.             

What proportion of the Caucasian population in the UK has Rh-ve blood group?         

Question 2.             

What proportion of the Rh+ve Caucasian population is homozygous for RhD?    

Question 3.             

What is the chance of a Rh-ve woman with a Rh+ve partner having a Rh-ve child?

Question 4.             

When was routine postnatal anti-D prophylaxis introduced in the UK?

Question 5.             

Where does anti-D for prophylactic use come from?

Question 6.             

How many deaths per 100,000 births were due to RhAI up to 1969?

Question 7.             

How many deaths per 100,000 births were due to RhAI in 1990?

Question 8.             

Anti-D was in short supply in 1969. Which non-sensitised, Rh-ve primigravidae with Rh+ve babies were not be given anti-D as a matter of policy?     

Question 9.             

List the possible reasons that a Rh-ve mother with a Rh+ve baby who does not receive anti-D might not become sensitised?

Question 10.         

What is the UK policy for the administration of anti-D after a term pregnancy?

Question 11.         

What is the alternative name of the Kleihauer test?

Question 12.         

What does the Kleihauer test do?

Question 13.         

How does the Kleihauer test work and what buzz words should you have in your head?

Question 14.         

When should a Kleihauer test be done after vaginal delivery?

Question 15.         

What blood specimen should be sent to the laboratory for a Kleihauer test?

Question 16.         

What steps should be taken to prevent sensitisation in the woman whose blood group is RhDu and whose baby is Rh+ve?

Question 17.         

The Kleihauer test is of value in helping to decide if antenatal vaginal bleeding or abdominal pain are due to placental abruption, with a +ve test confirming FMH and making abruption highly probable.  True/False?

Question 18.         

When should anti-D be offered?         

Question 19.         

When should a Kleihauer test be considered?                                                                               

Question 20.         

How often does the word “considered” feature in the GTG? The GTG has been archived, but I left this question to illustrate the point about ‘offered’ and ‘considered’.

Question 21.         

A Rh-ve woman miscarries a Rh+ve fetus at 18 week’s gestation. What should be done about Rhesus prophylaxis?

Question 22.         

A Rh-ve woman miscarries a Rh+ve fetus at 20 week’s gestation. What should be done about Rhesus prophylaxis?

Question 23.         

Which potentially sensitising events are mentioned in the GTG?

Question 24.         

What factors are listed in the GTG as particularly likely to be linked to FMH > 4 ml?

Question 25.         

A woman has recurrent bleeding from 20 weeks. What should be done about Rh prophylaxis?

Question 26.         

What are the key messages about giving RAADP?

Question 27.         

Which of the following statements, if any, is true of Rhesus negative volunteers given what should be a sensitising dose of Rh D?

A

all will produce anti-D

B

95% will produce anti-D

C

90 % will produce anti-D

D

80 % will produce anti-D

E

none of the above

Question 28.         

When a Rh-ve woman develops antibodies after a pregnancy, in what percentage of cases is the sensitising event identified?

A

10%

B

20%

C

30%

D

40%

E

>50%

Question 29.         

Which, if any, of the following statements is associated with an increased risk of significant Rhesus alloimmunisation.

A

anti-D occurring after a 1st. pregnancy

B

anti-D occurring after a 2nd. pregnancy

C

anti-D occurring after a 3rd. pregnancy

D

anti-D occurring after a 4th. pregnancy

E

anti-D occurring after multiple pregnancy

Question 30.         

A woman has FMH > 4ml. An appropriate additional dose of anti-D Ig is administered i.m. after taking advice from the consultant haematologist. When should a follow-up test be done to ensure that the fetal cells have been eliminated from the maternal circulation?

Question 31.         

A woman has FMH > 4ml. An appropriate dose of anti-D Ig is administered i.v. after taking advice from the consultant haematologist. When should a follow-up test be done to ensure that the fetal cells have been eliminated from the maternal circulation?

Question 32.         

A woman has a potentially sensitising event at <12 weeks. Which, if any, of the following investigations should be done?

Option list.

A

cffDNA

B

DAT

C

Kleihauer or equivalent test for feto-maternal haemorrhage

D

maternal blood group & antibody screen for anti-D

E

none of the above

Question 33.         

A woman has a potentially sensitising event at 16 weeks.

Which, if any, of the following investigations should be done?

Option list.

A

cffDNA

B

DAT

C

Kleihauer or equivalent test for feto-maternal haemorrhage

D

maternal blood group & antibody screen for anti-D

E

none of the above

Question 34.         

A woman has a potentially sensitising event at 22 weeks.

Which, if any, of the following investigations should be done?

Option list.

A

cffDNA

B

DAT

C

Kleihauer or equivalent test for feto-maternal haemorrhage

D

maternal blood group & antibody screen for anti-D

E

none of the above

Question 35.         

A woman has a potentially sensitising event at 32 weeks.

Which, if any, of the following investigations should be done?

Option list.

A

cffDNA

B

DAT

C

Kleihauer or equivalent test for feto-maternal haemorrhage

D

maternal blood group & antibody screen for anti-D

E

none of the above

Question 36.         

A woman has a potentially sensitising event. The laboratory is uncertain about her Rhesus group and declares the test to be indeterminate. How should the situation be dealt with?

Option list.

A

treat her as Rhesus -ve until a definitive result is available

B

treat her as Rh+ve until a definitive result is available

C

treat her as Rh Du until a definitive result is available

D

refer her to a fetal medicine expert

E

none of the above

Question 37.         

A woman has a complete miscarriage at 10 weeks confirmed by ultrasound scan. Which, if any, of the following investigations would be appropriate?

Option list.

A

cffDNA

B

DAT

C

Kleihauer or equivalent test for feto-maternal haemorrhage

D

maternal blood group & antibody screen for anti-D

E

none of the above

Question 38.         

A primigravida has a threatened miscarriage at 10 weeks. An ultrasound scan shows a viable intrauterine pregnancy. Which, if any, of the following investigations would be appropriate?

Option list.

A

antibody screen

B

cffDNA

C

DAT

D

Kleihauer test

E

maternal blood group

Question 39.         

A Rh-ve woman has a painless APH at 30 weeks. An ultrasound scan shows a viable intrauterine pregnancy. Which, if any, of the following investigations would be appropriate?

Option list.

A

antibody screen

B

cffDNA

C

DAT

D

Kleihauer test

E

maternal blood group

Question 40.         

A Rh-ve woman has a molar pregnancy identified and evacuated using suction at 10 weeks gestation. Which of the following statements, if any, is true?

Option list.

A

complete molar pregnancies have no fetal tissue so cannot be involved in Rh sensitisation

B

incomplete molar pregnancies have fetal tissue and can be involved in Rh sensitisation

C

molar pregnancies have significant potential for triggering Rh sensitisation

D

molar pregnancies generate potentials < 24 volts so cannot be involved in Rh sensitisation

E

none of the above

Question 41.         

A Rh-ve woman has a FDIU at 37 weeks. She declines intervention. Which, if any, of the following investigations should be offered?

A

DAT

B

Kleihauer or equivalent test for feto-maternal haemorrhage

C

maternal blood group & antibody screen for anti-D

D

placental biopsy

E

none of the above

Question 42.         

A Rh-ve woman has a FDIU at 37 weeks. She declines intervention and goes into labour at 40 weeks. She has a normal delivery but required manual removal of the placenta.

Which of the following statements, if any, are true about Rhesus prophylaxis?

Option list.

A

FMH estimation is important in relation to the FDIU

B

FMH estimation is important in relation to the mode of delivery & complications

C

FMH is minimal after FDIU and Rh D prophylaxis is irrelevant

D

FMH may have been the cause of the FDIU

E

None of the above and I am really fed up with this topic.

Question 43.         

A woman develops evidence of sudden-onset “fetal distress” in labour, C section is performed and an anaemic baby is delivered. FMH is suspected to be the cause of the “fetal distress” and the anaemia. When should samples of maternal blood be collected for testing for FMH?

Option List.

A

When the decision for C section was taken

B

At the time of delivery

C

30 – 120 minutes after the likely time of the FMH

D

4 hours after the likely time of the FMH

E

all of the above

F

none of the above

Question 44.         

A Rh-ve mother has C. section during which ICS is used. The baby’s blood group is Rh+ve. What is the minimum recommended dose of anti-D after return of the salvaged fetal red cells?

Option List.

A

250 IU

B

500 IU

C

1,000 IU

D

1,500 IU

E

2,000 IU

F

None of the above.

Question 45.         

Which, if any, of the following statements is true about current use of cffDNA for determination of the fetal Rhesus blood group  in the NHS?

Option List.

A

it is recommended for all Rh-ve women

B

it is recommended for consideration prior to RAADP use

C

it is recommended for all Rh-ve women prior to RAADP use

D

it is recommended for all Rh+ve women prior to RAADP use

E

it is not yet approved for use

F

none of the above

 

53.   EMQ. Tranexamic acid.

This topic featured in the exam in 2019.

Abbreviations.

GOH:          Goh E et al: “Perioperative management of women on oral anticoagulants and antiplatelet agents undergoing gynaecological procedures”.

TOG. 2020. Vol 22, Issue 2; Pages 131-6.

TA:              tranexamic acid.

Scenario 1.              

Which, if any, of the following describe the main mode of action of tranexamic acid? This is not a true EMQ as there may be more than one correct answer.

Option list.

A

inhibition of conversion of plasminogen to plasmin

B

inhibition of fibrinolysis

C

inhibition of factor Xa

D

inhibition of heparin activity

E

inhibition of plasmin activity

F

promotion of conversion of fibrinogen to fibrin

G

promotion of conversion of prothrombin to thrombin

H

promotion of platelet activation

I

promotion of platelet production

Scenario 2.              

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

Option list.

A

GOH say that TA should be considered when an apixaban antagonist is required

B

GOH say that TA should be considered when a clopidogrel antagonist is required

C

GOH say that TA should be considered when a factor Xa agonist is required

E

GOH say that TA should be considered when a factor Xa antagonist is required

F

GOH say that TA should be considered when a heparin  antagonist is required

G

GOH say that TA should be considered when Protein C is deficient

H

GOH say that TA should be considered when Protein S is deficient

I

none of the above

Scenario 3.              

Which, if any, of the following statements are true in relation to TA? This is not a true EMQ as there may be more than one correct answer.

Option list.

A

TA is teratogenic in rats and should be avoided in the first trimester

B

TA has not been shown to be teratogenic and is safe to use in pregnancy

C

TA is excreted is contraindicated in breastfeeding as the levels equate to maternal levels

D

TA levels in breast milk are one hundredth of maternal levels

E

none of the above.

Scenario 4.              

Which, if any, of the following statements are listed by eMC as contraindications?

Option list.

A

asthma

B

barbiturate use

C

consumption coagulopathy

D

convulsions

E

severe renal impairment

 

54.   Structured conversation. Apgar score.

The examiner will ask 8 questions.

 

55.   SBA. McCune-Albright syndrome.

Abbreviations.

MCA:            McCune Albright syndrome.

Scenario 1.              

Which, if any, of the following are components of the classical triad of MCA?

Option List

A

albinism

B

“cafè Cubano” spots feature

C

“Coast of California” pigmented areas

D

lentigo

E

osteomalacia

F

polyostotic fibrous dysplasia

G

precocious puberty

H

premature menopause

I

primary amenorrhoea

Scenario 2.              

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

Option List

A

it is an example of central primary amenorrhoea

B

it is an example of central secondary amenorrhoea

C

it is an example of central precocious puberty

D

it is an example of peripheral primary amenorrhoea

E

it is an example of peripheral secondary amenorrhoea

F

it is an example of peripheral precocious puberty

G

none of the above

Scenario 3.              

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

Option List

A

hyperthyroidism is common

B

hypothyroidism is common

C

thyroid function is similar to those without MCA

Scenario 4.              

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

Option List

A

excess growth hormone production  is common

B

inadequate growth hormone production is common

C

growth hormone production is similar to those without MCA

Scenario 5.              

Which, if any, of the following is true in relation to MCA?

Option List

A

inheritance is autosomal dominant

B

inheritance is autosomal recessive

C

inheritance is X-linked dominant

D

inheritance is X-linked recessive

E

inheritance is multifactorial

F

it is not a hereditary disorder

G

the aetiology is not genetic

H

none of the above

Scenario 6.              

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

Option List

A

renal artery stenosis is more common

B

renal cortex wasting is more common

C

renal phosphate wasting is more common

D

renal waisting is more common

E

none of the above.

Scenario 7.              

Approximately what % of children born to women with MCAS will have MCAS?

Option List

A

0

B

1 in 105 - 106

C

1 in 104

D

1 in 100

E

1 in 50

F

1 in 10

G

1 in 2

H

All

 

56. EMQ. Uterine inversion. .

Abbreviations.

MROP:          manual removal of placenta.

UI:                 uterine inversion.

Question 1.             

How is uterine inversion categorised and what how are the categories defined? This is not an EMQ and there is no option list.

Question 2.             

What is the approximate incidence of UI?

Option list.

A

1 in 1,000

B

1 in 2,000

C

1 in 4,000

D

1 in 6,000

E

1 in 10,000

F

1 in 20,000

G

1 in 100,00

Question 3.             

Is the incidence of UI higher in less-well developed countries?

Option list.

A

answer unknown

B

no

C

yes

Question 4.             

What is the approximate incidence of UI during Caesarean section?

Option list.

A

1 in 1,000

B

1 in 2,000

C

1 in 4,000

D

1 in 6,000

E

1 in 10,000

F

1 in 20,000

G

1 in 100,00

Question 5.             

Which, if any, of the following are described as risk factors for UI?

Option list.

A

abruptio placenta

B

Caesarean section

C

Credé’s manoeuvre

D

fundal placenta

E

hydramnios

F

lax uterus

G

Marfan syndrome

H

mismanagement of the 2nd. stage of labour

I

mismanagement of the 3rd.  stage of labour

J

oxytocic use

K

postpartum haemorrhage

L

short cord

Question 6.             

What are the presenting features of UI? There is no option list.

Question 7.             

What is the immediate management of UI? There is no option list.

Question 8.             

What procedure should be considered if the inversion is not corrected during initial management? There is no option list.

Question 9.             

What is Huntington’s procedure?.

Question 10.         

What is Haultain’s procedure ?

Question 11.         

What other procedures have been described? There is no option list.

Question 12.         

What should be done to ensure the inversion does not recur after successful replacement? There is no option list.

Question 13.         

What is the risk of recurrence in the next pregnancy? There is no option list.

 

Acute inversion of the uterus

With regard to acute uterine inversion,

1      it is spontaneous in up to 50% of cases.                                                                      True / False

2      its incidence is similar in most parts of the world.                                                    True / False

The associated risk factors for acute inversion of the uterus include:

3      injudicious traction on the umbilical cord.                                                                 True / False

4      manual removal of the placenta.                                                                                 True / False

5      uterine atony.                                                                                                                 True / False

6      fundal implantation of a morbidly adherent placenta.                                                 True / False

7      placenta praevia.                                                                                                            True / False

Recognised features of acute inversion of the uterus include:

8      haemorrhage.                                                                                                                 True / False

9      neurogenic shock.                                                                                                          True / False

10    severe abdominal pain.                                                                                                 True / False

11    postpartum collapse.                                                                                                     True / False

12    lump per vaginam.                                                                                                         True / False

Regarding management of acute uterine inversion,

13    the best treatment is immediate repositioning of the uterus.                                   True / False

14    the use of tocolysis to promote uterine relaxation will aid uterine reposition. True / False

15    magnesium sulphate is not used for tocolysis.                                                          True / False

16    in the presence of shock, terbutaline is acceptable as a safe agent  for uterine relaxation.

True / False

17    when halothane is used to encourage uterine relaxation severe hypotension is a recognised complication.                                                                                                    True / False

With regard to future pregnancy,

18    the condition carries a good prognosis if managed correctly.                               True / False

Regarding treatment of acute inversion,

19    in fewer than 3% of cases, women will need to undergo laparotomy.                          True / False

20    immediate reduction is successful in approximately 50–80% of cases.                        True / False