Tutorial 14 December 2020

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35	EMQ. Antenatal steroids
36	SBA. Coeliac disease & pregnancy
37	EMQ. HCV and pregnancy
38	EMQ. Kallmann’s syndrome
39	SBA. Fetal origins of adult disease

 

35.   EMQ. Antenatal steroids.

Abbreviations.

ANC:             antenatal corticosteroids.

ANS:              antenatal steroids.

NG25:           NICE’s Guideline 25: “Preterm labour and birth”. November 2015.

Lead-in.

The following scenarios relate to antenatal steroid use and the neonate.

There are no option lists and you have to decide your answers without help.

Scenario 1.

What are the benefits to the neonate of appropriate administration of antenatal steroids?

Scenario 2.

At what gestations should antenatal steroids be offered to women with singleton pregnancies who are at risk of premature labour?

Scenario 3.

At what gestations should antenatal steroids be offered to women with multiple pregnancies who are at risk of premature labour?

Scenario 4.

What advice is contained in NG25 about ANS and very early gestations?

Scenario 5.

What advice is contained in NG25 GTG about antenatal steroids and Caesarean section?

Scenario 6.

What advice is given in the NG25 about ANS in relation to the fetus with FGR at risk of premature delivery?

Scenario 7

What advice is given in NG25 about ANS for women with IDDM?

Scenario 8

What advice is in the NG25 about adverse effects of ANS on the fetus?

Scenario 9

What advice is in the GTG in relation to short-term maternal adverse effects?

Scenario 10

What contraindications to ANS are cited in NG25?

Scenario 11

What is the recommended drug regime for ANS administration?

Scenario 12.

What is the time-scale for maximum effect of ANS in reducing RDS?

Scenario 13.

When should repeat courses of ANS be given?

Scenario 14.

Who was the great pioneer of antenatal steroids to accelerate lung maturation?

Scenario 15.

Which country was this great pioneer from and which animal did he use for his early research?

Scenario 16.

Why is the story of this pioneer’s work a cautionary tale for O&G?

Scenario 17.

Which international organisation has immortalised his work in its logo?

Scenario 18.

When may antenatal steroids be beneficial to the fetus apart from accelerating lung maturation?

 

36.   SBA. Coeliac disease & pregnancy.

Abbreviations.

AGA:        anti-gliadin antibodies 

CD:          coeliac disease.

DGP:        IgG deamidated gliadin peptide.

EMA:       IgG endomysial antibodies. 

FGR:        Fetal growth restriction.

HLA:        Human leucocyte antigen.

IgA:          immunoglobulin A. 

tIgA:        total immunoglobulin A.

tTGA:       IgA tissue transglutaminase antibody.

vLBW:      very low birth weight.

vPTB:       very pre-term birth (<30/52).

Question 1.

What is coeliac disease?

Option List

A.	allergy to gluten
B.	malabsorption due to large bowel inflammation
C.	an auto-immune disorder triggered by gluten sensitivity causing villous atrophy of the descending colon in individuals with a genetic predisposition
D.	an auto-immune disorder triggered by gluten sensitivity causing villous atrophy of the gastric mucosa in individuals with a genetic predisposition
E.	an auto-immune disorder triggered by gluten sensitivity causing villous atrophy of the small bowel in individuals with a genetic predisposition

Question 2.

What is the prevalence of coeliac disease in women of reproductive age?

Option List

A.	0.1%
B.	0.5%
C.	1%
D.	2-5%
E.	5-10%

Question 3.

Which of the following groups have an increased risk of CD?

Option List

A.	1st. degree relatives of those with CD
B.	those with type 1 diabetes
C.	those with iron deficiency anaemia
D.	those with osteoporosis
E.	those with unexplained infertility

Question 4.

Which of the following are features of CD in the non-pregnant population?

Option List

A.	abdominal bloating and pain
B.	amenorrhoea
C.	anaemia
D.	recurrent miscarriage
E.	unexplained infertility

Question 5.

How do pregnant women with CD present most commonly?

Option List

A	anaemia
B	failure to gain weight in pregnancy
C	intra-uterine growth retardation
D	low BMI
E	no recognised abnormality

Question 6.

Which of the following commonly occur in pregnant women with CD?

Option List

A	anaemia
B	failure to gain weight in pregnancy
C	intra-uterine growth retardation
D	low BMI
E	no recognised abnormality

Question 7.

How should the woman with suspected CD be investigated initially?

Option List

A.	jejunal biopsy
B.	IgA EMA
C.	IgA tTGA
D.	IgA EMA + IgA tTGA
E.	tIgA + tTGA

Question 8.

Which, if any, of the following statements are true in relation to the woman due to have testing for suspected CD?

Option List

A.	continue with a diet that includes gluten ≥ once daily for at least 1 month
B.	continue with a diet that includes gluten ≥ once daily for at least 6 weeks
C.	continue with a diet with ≥ 10 gm. gluten daily for at least 1 month
D.	continue with a diet with ≥ 10 gm. gluten daily for at least 6 weeks
E.	follow a strict gluten-free diet for at least 3 months

Question 9.

What advice should be given to those who have gone on to a gluten-free diet in the month before testing?

Option List

A.	the gluten-free diet may render the serological tests –ve, but not intestinal biopsy
B.	the gluten-free diet may render the intestinal biopsy –ve, but not the serological tests
C.	the gluten-free diet may render all the tests -ve
D.	if she is happy with the gluten-free diet, there is no  point in testing
E.	she is not qualified to make medical decisions and should not be so stupid on future occasions

Question 10.

Which of the following conditions should make consideration of testing for CD sensible?

Option List

A.	amenorrhoea
B.	Down’s syndrome
C.	epilepsy
D.	recurrent miscarriage
E.	Turner’s syndrome
F.	unexplained infertility

Question 11.

What recommendation does NICE make about the information to be provided to healthcare professionals with the results of serological tests for CD?

Option List

A.	the results alone should be provided
B.	the results with the local reference values for children, adult men and adult women
C.	the results with the local and national reference values for children, adult men and women
D.	the results with interpretation of their meaning
E.	the results with interpretation of their meaning + recommended actions

Question 12.

How is the diagnosis of CD confirmed after +ve serological testing?

Option List

A.	colonoscopy
B.	enteroscopy
C.	gastroscopy
D.	rectal biopsy
E.	small bowel biopsy

Question 13.

Which skin condition is particularly associated with CD?

Option List

A.	atopic eczema
B.	dermatitis herpetiformis
C.	dermatitis multiforme
D.	dermatographia
E.	psoriasis

Question 14.

Which of the following are likely to be absorbed less well than normally in women with CD?

Option List

A.	carbohydrate
B.	fat
C.	folic acid
D.	protein
E.	vitamins B12, D & K

Question 15.

What is the appropriate treatment of CD?

Option List

A.	antibiotics: long-term in low-dosage
B.	azathioprine
C.	cyclophosphamide
D.	rectal steroids
E.	none of the above

Question 16.

Which of the following do not contain gluten?

Option List

A.	barley
B.	oats
C.	rapeseed oil
D.	rye
E.	wheat

 

37.   EMQ. HCV and pregnancy.

Lead-in.

Some of the questions are not true EMQs as more than one of the options is true.

Abbreviations.

DAAD:           Direct-acting, antiviral drug.

HBcAg:          Hepatitis B core antigen

HCV:             Hepatitis C virus.

HCAb:           Hepatitis C antibody.

MTCT:           mother-to-child transmission.

NICU:            neonatal intensive-care unit,

PTB:              preterm birth,

STD:              sexually-transmitted disease.

Scenario 1.              

Which, if any, of the following statements are true?

Option list.

A	Hepatitis kills more people world-wide than HIV
B	Hepatitis kills more people world-wide than TB
C	Hepatitis B kills more people world-wide that Hepatitis C
D	Hepatitis B kills more people world-wide than TB
E	None of the above

Scenario 2.              

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

Option list.

A	It is a DNA virus
B	It is a RNA virua
C	It is a member of the Flaviviridae family
D	it is a member of the Hepadnaviridae family
E	it is a member of the Herpesviridae family
F	most infections are due to genotypes 1 & 3
G	most infections are due to genotypes 2 & 4

Scenario 3.              

What is the approximate prevalence of HCV infection in the UK?

Option list.

A	0.1 per 1,000
B	0.3 per 1,000
C	0.5 per 1,000
D	1 per 1,000
E	3 per 1,000
F	5 per 1,000
G	10 per 1,000
H	13 per 1,000
I	15 per 1,000
J	None of the above

Scenario 4.              

What are the key aspects of the WHO’s Global Health Sector Strategy in relation to HCV infection?

Option list.

A	elimination as a as a major public health threat by 2020
B	elimination as a as a major public health threat by 2030
C	elimination as a as a major public health threat by 2040
D	reduction in incidence by 50% by 2030
E	reduction in incidence by 75% by 2030
E	reduction in incidence by 80% by 2030
F	reduction in mortality by 50% by 2030
G	reduction in mortality by 65% by 2030
H	reduction in mortality by 70% by 2030

Scenario 5.              

What is the incubation period of HCV infection?

Option list.

A	6 weeks
B	2 months
C	up to 3 months
D	up to 4 months
E	up to 6 months
F	up to 12 months
G	none of the above

Scenario 6.              

What symptoms are most common in acute HCV infection? There is no option list.

Scenario 7.              

How is acute HCV infection diagnosed?

Option list.

A	clinically
B	presence of HCV antibody
C	presence of HCV IgM
D	presence of HCV IgG
E	presence of HCV RNA
F	none of the above

Scenario 8.              

What proportion of those with acute HCV infection are asymptomatic?

Option list.

A	10%
B	20%
C	50%
D	60%
D	70%
E	> 80%

Scenario 9.              

When does continuing infection after initial exposure become defined as chronic infection?

Option list.

A	after 6 weeks
B	after 2 months
C	after 3 months
D	after 4 months
E	after 6 months
F	after 12 months
G	none of the above

Scenario 10.           

Approximately how many of those with acute HCV infection will go on to chronic infection?

Option list.

A	10%
B	20%
C	40%
D	50%
E	>50%
F	>70%

Scenario 11.           

A woman is found to have HCV antibodies. Which, if any, of the following statements could be true?

Option list.

A	she could have acute HCV infection
B	she could have chronic infection
C	she could have had HCV infection that has cleared spontaneously
D	she could have had HCV infection that has responded to drug therapy
E	she could have a false +ve test result
F	she could have chronic HBV infection due to cross reaction with HBcAg
G	she is immune to HCV
H	the antibodies could result from HCV vaccine
I	the antibodies could result from yellow fever vaccine
J	none of the above

Scenario 12.           

Which, if any, of the following statements reflect current thinking about the mechanisms of damage in chronic HCV infection?

Option list.

A	hepatic damage is proportional to the duration of HCV infection
B	hepatic damage is a direct result of HCV replication within hepatocytes
C	hepatic damage is proportional to the level of detectable HCV RNA in maternal blood
D	hepatic damage is immune-mediated
E	hepatic damage is due to progressive biliary tract infection, scarring  and stenosis
F	hepatic damage mostly occurs in women who abuse alcohol
G	hepatic damage is worse in women with co-existing HIV infection
H	hepatitis D is end-stage hepatitis C, with cirrhosis and liver failure, ‘D’ originating from the original name: ‘deadly-stage’ HCV disease

Scenario 13.           

How common is vertical transmission? There is no option list.

Scenario 14.           

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

A	acute hepatitis is notifiable
B	chronic hepatitis is notifiable
C	hepatitis A is notifiable as the main route of spread is faecal contamination of food & water
D	hepatitis D is notifiable as the main source of infection is infected food and water
E	hepatitis E is notifiable as the main source of infection in the UK is raw or undercooked pork
F	none of the above

Scenario 15.           

What anti-viral treatment is recommended for pregnancy? There is no option list.

Scenario 16.           

Which, if any, of the following are true about Ribavirin?

Option list.

A	it is the least expensive of the new DAADs for HCV
B	it is the least toxic of the new DAADs for HCV
C	it is the most effective of the new DAADs for HCV
D	it is contraindicated in pregnancy because of fears of teratogenicity
E	can cause sperm abnormalities
F.	can persist in humans for up to 6 months
G.	none of the above

Scenario 17.           

A woman with chronic HCV wishes to breastfeed. What advice would you give? There is no option list.

Scenario 18.           

How is neonatal infection diagnosed? There is no option list.

Scenario 19.           

How is neonatal infection treated? There is no option list.

Scenario 20.           

Which, if any, of the following conditions is more common in women with HCV infection?

Option list.

A	dermatitis herpetiformis
B	HELLP syndrome
C	obstetric cholestasis
D	postnatal depression
E	thrombocytopenia

Scenario 21.           

By how much is the risk of the condition in question 20 increased in women with HCV?

Option list.

A	by a factor of 2
B	by a factor of 5
C	by a factor of 20
D	by a factor of 50
E	none of the above

Scenario 22.           

Which, if any, of the following statements is true about HCV and the Nobel Prize?

Option list.

A	the Nobel Prize was awarded to Alter, Houghton & Rice in 2020
B	the Nobel Prize was awarded to Alter, Hogg & Rice in 2020
C	the Nobel Prize was awarded to Alter, Houghton & Rees in 2020
D	the Nobel Prize was awarded to Change, Houghton & Rice in 2020
E	the Nobel Prize was awarded to Change, Hogg & Rice in 2020
F	the Nobel Prize was awarded to Change, Hogg & Barleycorn in 2020
G	the Nobel Prize has not been awarded for work on HCV

 

38.   EMQ. Kallmann’s syndrome.

Scenario 23.           

Which of the following might be included in descriptions of Kallmann’s syndrome?

Option list.

A	hypogonadotrophic hypogonadism
B	hypogonadotrophic hypogonadism + anosmia
C	hypogonadotrophic hypogonadism + anosmia + colour-blindness.
D	hypogonadotrophic hypogonadism due to uterine agenesis

Scenario 24.           

Which, if any, of the following are features of the Kallmann phenotype?

A	absent or minimal breast development
B	aortic stenosis
C	blue eyes
D	blue hair
E	hot flushes
F	short stature
G	tall stature
H	vaginal agenesis
I	none of the above

Scenario 25.           

How common is Kallmann’s syndrome and what is the female: male ratio?

A	1 in 1,000 and F:M ratio 1:1
B	1 in 5,000 and F:M ratio 1:1
C	1 in 10,000 and F:M ratio 1:4
D	1 in 50,000 and F:M ratio 1:4
E	1 in 100,000 and F:M ratio 1:8
F	1 in 250,000 and F:M ration 1:10

Scenario 26.           

What is the most common mode of inheritance of Ks?

Option list.

A	hypogonadotrophic hypogonadism
B	hypogonadotrophic hypogonadism + anosmia
C	hypogonadotrophic hypogonadism due to uterine agenesis
D	autosomal dominant
E	autosomal recessive
F	X-linked recessive
G	new mutation of the ANOS1 gene
H	the most common mode of inheritance is not known

Scenario 27.           

How is Kallmann’s syndrome diagnosed?

A	abdominal and pelvic ultrasound scan
B	cell-free fetal DNA
C	chromosome analysis
D	CT scan of hypothalamus / pituitary
E	MR scan of hypothalamus / pituitary
F	none of the above.

Scenario 28.           

How is Kallmann’s syndrome treated initially? Which of the following statements are true?

Option list.

A	GnRH analogue depot
B	pulsatile GnRH therapy
C	combined oral contraceptive
D	counselling & education re gender re-assignment
E	depot progestogen
F	none of the above

Scenario 29.           

A woman was diagnosed with Kallmann’s syndrome at 16 and had successful initial treatment. She is now 25, married and wishes to have a pregnancy. She has had pre-pregnancy assessment and counselling. Which of the following should be considered?

A	GnRH analogue depot
B	induction of ovulation with clomiphene
C	gonadotrophin therapy
D	pulsatile GnRH therapy
E	none of the above

 

39.   SBA. 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                              

A.	the Barker hypothesis
B.	the Baker’s dozen
C.	the Broadbank theory
D.	PIPAD: Placental Insufficiency Programmes Adult Disease
E.	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