|
27 |
Role-play. Anencephaly. |
|
28 |
Role-play. Huntington’s disease. |
|
29 |
EMQ. Hepatitis B |
|
30 |
EMQ. Mycoplasma genitalium. |
27. Anencephaly.
Candidate’s instructions.
You are an SpR5 and
running the ante-natal clinic – your consultant has been called to help a
consultant colleague with an emergency on the labour unit and is not available
for advice.
You are about to see Jean
Hathersage. She is 25 years old and had a 10-week scan last week that showed
anencephaly. She stated that she did not want TOP. She was counselled, given
information leaflets and asked to return to the antenatal clinical today for
further discussion. Your task is to conduct that discussion.
28. Huntington’s disease.
Candidate's Instructions.
You are the SpR in the
pre-pregnancy counselling clinic.
Mary Smith has been
referred.
The GP referral letter is
brief. “Please see this woman who is considering becoming pregnant. Her father
has Huntington’s chorea, about which I know very little.”
Your task is to take a
history and advise about appropriate investigations.
29. Hepatitis
B and pregnancy.
Abbreviations.
GDM: gestational diabetes mellitus.
HAV: hepatitis A virus
HBcAg: hepatitis B core antigen
HBeAg: hepatitis B e antigen
HBsAg: hepatitis B surface antigen
HBcAb: antibody to hepatitis B core antigen
HBeAb: antibody to hepatitis B e antigen
HBsAb: antibody to hepatitis B surface antigen
HBIG: hepatitis B immunoglobulin
HBV: hepatitis B virus
HBcAg: hepatitis B core antigen
HBeAg: hepatitis B e antigen
HBsAg: hepatitis B surface antigen
HBcAb: antibody to hepatitis B core antigen
HBeAb: antibody to hepatitis B e antigen
HBsAb: antibody to hepatitis B surface antigen
HBIG: hepatitis B immunoglobulin
HCV: hepatitis C virus
HEV: hepatitis E virus
HSV: herpes simplex virus
VT: vertical transmission
Question 1.
An asymptomatic primigravida books at 10 weeks. Her partner had an
acute HBV infection 4 months ago. What results on routine blood testing would
indicate that she has an acute HBV infection?
Question 2.
An asymptomatic primigravida books at 10 weeks. Her partner had an
acute HBV infection 4 months ago. What results on routine blood testing would
indicate that she is immune to the HBV as a result of infection?
Question 3.
An asymptomatic primigravida books at 10 weeks. Her partner had an
acute HBV infection 4 months ago. What results on routine blood testing would
indicate that she is immune to the HBV as a result of HBV vaccine?
Question 4.
An asymptomatic primigravida books at 10 weeks. Her partner had an
acute HBV infection 9 months ago. What results on routine blood testing would show
that she is a chronic carrier of HBV infection?
Question 5.
Testing
shows that he is positive for HBsAg, positive for HBcAb but negative for IgM HBcAb.
What does this mean in relation to his HBV status?
Question 6.
Testing
shows that he is negative for HBsAg, positive for HBcAb and positive for HBsAb.
What
does this mean in relation to his HBV status?
Question 7.
How common is chronic HBV carrier status in UK pregnant women?
Question 8.
What is the risk of death from chronic HBV carrier status?
Question 9.
A primigravid woman at 8 weeks gestation is found to be non-immune
to HBV. She has recently married and her husband is a chronic carrier. What
should be done to protect her from infection?
Question 10.
A woman is a known carrier of HBV. What is the risk of vertical
transmission in the first trimester?
Question 11.
What is the risk of the neonate who has been infected by vertical
transmission becoming a carrier without treatment?
Question 12.
Should antiviral maternal therapy in the 3rd. trimester
be considered for women with HBeAg or high viral load?
Question 13.
How effective is hepatitis B prophylaxis for the neonate in
preventing chronic carrier status as a result of vertical transmission?
Question 14.
Can a woman who is a chronic HBV carrier breastfeed safely?
Question 15.
Hepatitis
B infection is the most dangerous of the viral hepatitis infections in
pregnancy.
Question 16.
A pregnant woman who is not immune to HBV has a partner who is a
chronic carrier. Can HBV vaccine be administered safely in pregnancy?
Question 17.
How long can HBV survive outside the body?
Question 18.
A pregnant woman who is not immune has a partner with acute
hepatitis due to HBV. He cuts his hand and bleeds onto the kitchen table. How
should she clean the surface to ensure that she gets rid of the virus?
Is it true that the
presence of HBeAg in maternal blood is a particular risk factor for vertical
transmission? Not really a scenario, but never mind!
Question 20.
What does 5 log10 copies
/mL mean?
|
A |
> 10 copies / mL |
|
B |
> 100 copies / mL |
|
C |
> 1,000 copies / mL |
|
D |
> 10,000 copies / mL |
|
E |
> 100,000 copies /
mL |
|
F |
this has scared me witless
and I am going straight home to complain to my Mum |
Question 21.
Which, if
any, of the following statements are true about amniocentesis and CVS and the
risk of vertical transmission if the mother is HbsAg+ve?
Option
list.
|
A |
they are contraindicated |
|
B |
they should
be done with cover with HBIG |
|
C |
they should
be done with cover with a drug that is
effective for HBV and safe in pregnancy. |
|
D |
none of the
above |
Question 22.
Which, if any, of the following statements are true about treatment
in the third trimester to reduce the risk of vertical transmission?
Option list.
|
A |
women who are HbsAg+ve should be offered testing for HBV DNA
levels in the 3rd. trimester |
|
B |
there is no effective treatment for HBV in the 3rd.
trimester |
|
C |
the risks of treatment for HBV in the 3rd. trimester outweigh
the benefits |
|
D |
drug treatment for HBV in the 3rd. trimester adds
nothing beneficial to the normal use of HBIG + HB vaccination of the neonate |
|
E |
none of the above. |
Question 23.
Which, if any, of the following drugs is recommended for use in
the third trimester to reduce the risk of vertical transmission?
Option list.
|
A |
acyclovir |
|
B |
lamivudine |
|
C |
telbivudine |
|
D |
tenofovir |
Question 24.
Does elective Cs before labour and with the membranes intact reduce
the vertical transmission rate?
Question 25.
Which hepatitis virus normally produces a mild illness, but
represents a major risk to pregnant women, with a mortality rate of up to 5%?
Question 26.
A pregnant woman has a history of viral hepatitis and informs the
midwife at booking that she is a carrier and that she has a significant risk of
cirrhosis and has been advised not to drink alcohol. Which is the most likely
hepatitis virus?
Question 27.
Which hepatitis virus is an absolute contraindication to
breastfeeding after appropriate treatment of the infected mother and
prophylaxis for the baby?
Question 28.
Which hepatitis virus is linked to an increased risk of obstetric
cholestasis?
Question 29.
Which, if any, of the following statements is true in relation to
HepB and the risk of GDM?
Option list.
|
A |
the risk is about the same |
|
B |
the relative risk is about 0.1. |
|
C |
the relative risk is about 0.2. |
|
D |
the relative risk is about 0.5. |
|
E |
the relative risk is about 1.2. |
|
F |
the relative risk is about 1.5. |
|
G |
the relative risk is about 2.0 |
|
H |
the relative risk is about 3.0 |
|
I |
the risk is unknown |
Lead-in.
Many of the questions
are not true EMQs as they have more than one correct answer. I have tried to
include all the facts I think might feature in the exam and packing more than
one into a question reduces the total number of questions and makes the document
a bit more manageable. It also reduces the amount of typing I have to do.
Abbreviations.
BASSH: British Association for Sexual Health and HIV.
BASHHMG: British Association for Sexual Health and HIV’s
“National
guideline for the management of infection with Mycoplasma genitalium”. 2018
MG: Mycoplasma genitalium.
NHSCS: NHS Cervical
Screening Programme
Which,
if any, of the following statements are true in relation to MG? This is not a true
EMQ as there may be more than one correct answer.
Option list.
|
A |
MG was first
isolated in 2001 |
|
B |
MG was first
isolated from men with non-gonococcal urethritis (NGU) |
|
C |
MG belongs to
the Cutemollies class |
|
D |
MG is the smallest
known yeast with the ability to self-replicate |
|
E |
MG is the smallest
known bacterium with the ability to self-replicate |
|
F |
MG has an unusual,
double-layered cell wall |
|
G |
MG has an
unusual protrusion at one end |
|
H |
MG’s protrusion
enables it to adhere to epithelial cells |
|
I |
MG’s
protrusion enables it to invade epithelial cells |
|
J |
MG is best
seen on a Gram stain |
Scenario 2.
Which, if any, of the following statements
are true in relation to Mycoplasmas?
Option
list.
|
A |
are the largest known bacteria |
|
B |
have no cell wall |
|
C |
have no nuclei |
|
D |
are resistant to ß-lactam antibiotics |
|
E |
are resistant to sulphonamides |
|
F |
colonies show a ‘scrambled egg’ appearance on culture
on agar |
|
G |
particularly affect mucosal surfaces |
Scenario 3.
Which, if any, of the following statements
are true in relation to Mg?
Option
list.
|
A |
when the organism was originally found, culture took
50 days |
|
B |
Mg is facetious |
|
C |
Mg is a facultative aerobe |
|
D |
Mg is a facultative anaerobe |
|
E |
Mg is a facultative aerobe & anaerobe |
|
F |
Mg is fastidious |
Scenario 4.
Which, if any, of the following are true in
relation to the approximate prevalence of MG?
Option
list.
|
A |
it is ~ 0.1% |
|
B |
it is ~ 1.0% |
|
C |
it is ~ 5.0% |
|
D |
it is ~ 5-10% |
|
E |
it is > 10% |
|
F |
none of the above |
Scenario 5.
Which, if any, of the following is true in
relation to screening for MG? This is a true EMQ with only one correct answer.
Option
list.
|
A |
screening for MG is now included in the NCSP |
|
B |
screening for MG is now offered as part of the NHSCS |
|
C |
screening should be offered to all sexually active
women < 30 years old |
|
D |
screening should only be offered to those with symptoms
suggestive of infection |
|
E |
screening should be offered to all partners of those
with MG infection |
|
F |
none of the above |
Scenario 6.
Which, if any, of the following are
included in BASHHMG as risk factors for infection with MG?
Option
list.
|
A |
Cigarette smoking |
|
B |
Multiple dancing partners |
|
C |
Multiple sexual partners |
|
D |
Non-white ethnicity |
|
E |
Younger age |
|
F |
None of the above |
Scenario 7.
Which of the following statements is true
in relation to MG and co-infection with other organisms?
Option
list.
|
A |
MG excretes bactericidal toxins and co-infection is
rare |
|
B |
MG co-infection is most often with chlamydia |
|
C |
MG co-infection is most often with E. coli |
|
D |
MG co-infection is most often with HIV |
|
E |
MG co-infection is most often with TB |
|
F |
None of the above |
Scenario 8.
Which of the following statements is true
in relation to MG and men?
Option
list.
|
A |
It is the most common cause of NGU |
|
B |
It is the most common cause of epididymitis |
|
C |
It is the most common cause of prostatitis |
|
D |
It is a well-recognised cause of male sub-fertility |
|
E |
Most men with MG infection are asymptomatic |
|
E |
None of the above |
Scenario 9.
Which, if any, of the following statements
are true in relation to MG and women?
Option
list.
|
A |
MG is linked to an ↑ risk of cervicitis |
|
B |
MG is linked to an ↑ risk of endometritis |
|
C |
MG is linked to an ↑ risk of female infertility |
|
D |
MG is linked to an ↑ risk of miscarriage |
|
E |
MG is linked to an ↑ risk of otitis media |
|
F |
MG is linked to an ↑ risk of pelvic inflammatory disease |
|
G |
MG is linked to an ↑ risk of postcoital bleeding |
|
H |
MG is linked to an ↑ risk of postmenopausal bleeding |
|
I |
MG is linked to an ↑ risk of preterm birth |
|
J |
MG is linked to an ↑ risk of damage to Fallopian tube cilia |
|
K |
MG is linked to an ↑ risk of puerperal psychosis |
|
L |
MG is linked to an ↑ risk of puerperal sepsis |
|
M |
Most infected women are asymptomatic |
|
N |
None of the above |
Scenario 10.
Which, if any, of the following statements
are true in relation to current concerns about Mg?
Option
list.
|
A |
It could become a ‘superbug’, resistant to most
antibiotics, within a decade |
|
B |
Infection is often misdiagnosed as chlamydia with ↑ risk of antibiotic resistance |
|
C |
‘superbug’ status would be likely to lead to an ↑ in renal failure |
|
D |
‘superbug’ status would be likely to lead to an ↑ in female infertility |
|
E |
‘superbug’ status would be likely to lead to an ↑ in male infertility |
Scenario 11.
Which, if any, of the following are used
in the recommended test for MG infection in women?
Option
list.
|
A |
blood testing for MG IgG |
|
B |
blood testing for MG IgM |
|
C |
cervical smears checked microscopically for the
diagnostic intracellular inclusion bodies |
|
D |
culture and sensitivity of cervical swab specimens
using MG-specific culture medium |
|
E |
culture and sensitivity of 1st. void MSSU using MG-specific
culture medium |
|
F |
culture and sensitivity of vaginal swab specimens
using MG-specific culture medium |
|
G |
NAATs that detect the MG G-antigen |
|
H |
NAATs that detect MG DNA |
|
I |
NAATs that detect MG RNA |
|
J |
serum testing for MG-specific antigen |
|
K |
vaginal swabs taken by the woman |
|
L |
none of the above |
Scenario 12.
Which, if any, of the following statements
are true in relation to testing for antibiotic resistance after initial tests
are +ve for MG?
Option
list.
|
A |
test for resistance to cephalosporins |
|
B |
test for resistance to macrolides |
|
C |
test for resistance to penicillin |
|
D |
test for resistance to quinolones |
|
E |
test for resistance to macrolides |
|
F |
test for resistance to streptomycin |
|
F |
test for resistance to sulphonamides |
|
F |
test for resistance to tetracyclines |
|
G |
None of the above |
Which,
if any, of the following statements are true in relation to estimates of antibiotic
resistance in current strains of MG in the UK?
Option list.
|
A |
20% are
resistant to cephalosporins |
|
B |
40% are
resistant to macrolides |
|
C |
50% are
resistant to penicillin |
|
D |
50% are
resistant to quinolones |
|
E |
10% are
resistant to streptomycin |
|
F |
90% are
resistant to sulphonamides |
|
F |
40% are
resistant to tetracyclines |
|
F |
None of the
above |
Scenario 14.
Which, if any, of the following is BASHHMG’s
recommended 1st. line treatment of uncomplicated MG?
Option
list.
|
A |
azithromycin 1 gram daily for 7 days |
|
B |
doxycycline 100 mg twice daily for 7 days |
|
C |
doxycycline 100 mg twice daily for 10 days |
|
D |
doxycycline 100 mg twice daily for 7 days |
|
E |
doxycycline 100 mg twice daily for 7 days then azithromycin
1 gram daily for 2 days |
|
F |
moxifloxacin 400mg orally once daily for 7 days |
|
G |
moxifloxacin 400mg orally once daily for 10 days |
|
H |
none of the above |
Scenario 15.
Lead-in
Which, if any, of the following is BASHHMG’s
recommended 1st. line treatment of complicated MG?
Option
list.
|
A |
doxycycline 100 mg twice daily for 10 days |
|
B |
doxycycline 100 mg twice daily for 14 days |
|
C |
moxifloxacin 400mg orally once daily for 10 days |
|
D |
moxifloxacin 400mg orally once daily for 14 days |
|
E |
none of the above |
Scenario 16.
Lead-in
This is not an EMQ or SBA!
Fill in the gaps in the table below, using
option list.
Option
list.
|
A |
aminoglycoside |
|
B |
cephalosporin |
|
C |
macrolide |
|
D |
penicillin |
|
E |
quinolone |
|
F |
tetracycline |
Table.
|
Drug
name |
Category
of drug |
|
azithromycin |
|
|
doxycycline |
|
|
moxifloxacin |
|
Scenario 17.
Which, if any, of the following statements
is true in relation to test of cure (TOC) after treatment of MG?
Option
list.
|
A |
TOC should be offered to everyone who has been
treated for MG |
|
B |
TOC should only be offered to those who had signs of
infection before treatment |
|
C |
TOC should only be offered to those who had symptoms
of infection before treatment |
|
D |
TOC should only be offered to those who had signs
and symptoms before treatment |
|
E |
TOC should only be offered to those who continue to
have signs or symptoms two weeks or more after the start of treatment |
|
F |
none of the above |
Scenario 18.
Which, if any, of the following statements
are true in relation to the timing of test of cure (TOC) after treatment of MG?
Option
list.
|
A |
TOC is best done at 3 weeks after start of treatment |
|
B |
TOC is best done at 4 weeks after start of treatment |
|
C |
TOC is best done at 5 weeks after start of treatment |
|
D |
TOC is best done at 6 weeks after start of treatment |
|
E |
TOC should not be done < 2 weeks from the start
of treatment |
|
F |
TOC should not be done < 3 weeks from the start
of treatment |
|
G |
TOC should not be done < 4 weeks from the start
of treatment |
.
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