Monday 22 February 2021

Tutorial 22 February 2021

 

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36

Role-play. Menorrhagia

37

Structured discussion. The uses of MgSO4 in O&G.

38

EMQ. Gp B streptococcus and pregnancy

39

EMQ. Retinoids and pregnancy

40

Caldicott guardian.

41

EMQ. Tetracyclines and pregnancy

 36.         Role-play. Menorrhagia.

Candidate’s instructions.

You are an ST5. A patient has been aggressive towards the reception and nursing staff, insisting that she must see the consultant, not a junior doctor. She shouted at both the receptionist and the nurses, saying: ‘I want to see the organ grinder, not the bloody monkey’. The consultant says that she has no intention of seeing her and that you need to learn to deal with difficult patients.

 

37.         Structured discussion. The uses of MgSO4 in O&G.

Candidate’s instructions.

This is a structured discussion about the uses of MgSO4 in O&G, with a very simple structure.

The examiner will ask what you know about the subject but not ask questions, prompt or otherwise assist. It is up to you to give as full an account of the uses as you can muster.

 38.         Gp B streptococcus and pregnancy

Group B Streptococcus. EMQ. Answer.

Abbreviations.

ASAP:            as soon as possible.

ASB:              asymptomatic bacteruria

UKOSS:         UK Obstetric Surveillance System.

CDC:              USA’s. Centers for Disease Control and Prevention.

EDD:             expected date of delivery.

EOGBSD:      early onset GBSD.

GBS:              group B streptococcus; full title: ‘Lancefield group B beta-haemolytic streptococcus’.

GBSD:           GBS disease.

GBSIP:           GBS in pregnancy.

GTG36:         RCOG’s Green-top guideline 36: GBS Disease, Early-onset”. 2017.

IAP:               intrapartum antibiotic prophylaxis.

LOGBSD:       late-onset GBSD.

MSU:            mid-stream specimen of urine

PCR:              polymerase chain reaction.

PIF:                patient information leaflet.

PPROM:        preterm, prelabour rupture of membranes.

RCT:              randomised control trial.

SROM:          spontaneous rupture of membranes.

UKOSS:         UK Obstetric Surveillance System.

UTI:               urinary tract infection.

Option list 1.

A

< 5%

B

10%

C

15%

D

20%

E

30%

F

40%

G

50%

H

>50%

Question 1.             

Which condition is of greatest significance in relation to GBSIP?

Option list.

A

chorio-amnionitis

B

early-onset GBS disease in the neonate

C

late -onset GBS disease in the neonate

D

maternal urinary tract infection

E

maternal pneumonia

F

puerperal endometritis

G

stillbirth

H

none of the above

Question 2.             

What is the incidence of the condition of greatest significance in relation to GBSD?

Use Option list 1.

Question 3.             

Approximately how common is GBS colonisation in adults? Use Option List 1.

Question 4.             

What is the approximate rate of vertical transmission in cases of maternal GBS colonisation?

Use Option List 1

Question 5.             

Approximately how many neonates will develop EOGBSD in cases of maternal GBS colonisation?

Use Option List 1

Question 6.             

What is the first statement in the executive summary section of GTG36?

Option list.

A

all pregnant women should be provided with an appropriate PIF

B

all pregnant women should be given web addresses for GBS information website

C

clinicians should know the risk factors for EOGBSD

D

clinicians should know the relative risk for EOGBSD associated with the main risk factors

E

universal bacteriological screening is not recommended

Question 7.             

What is the second statement in the executive summary section of GTG36?

Option list.

A

all pregnant women should be provided with an appropriate PIF

B

all pregnant women should be given web addresses for GBS information website

C

clinicians should know the risk factors for EOGBSD

D

clinicians should know the relative risk for EOGBSD associated with the main risk factors

E

universal bacteriological screening is not recommended

Question 8.             

What is the third statement in the executive summary section of GTG36?

Option list.

A

all pregnant women should be provided with an appropriate PIF

B

all pregnant women should be given web addresses for GBS information website

C

clinicians should know the risk factors for EOGBSD

D

clinicians should know the relative risk for EOGBSD associated with the main risk factors

E

universal bacteriological screening is not recommended

Question 9.             

What risk factors for EOGBSD are listed in GTG36? There is no option list – that would be too easy. Just write what you know to be the main risk factors.

Question 10.         

A woman was a GBS carrier in pregnancy. What is the risk of recurrence in a future pregnancy?

Use Option List 1

Question 11.         

What management options should be offered to a pregnant woman with a history of a previously affected baby but no evidence of GBS in the current pregnancy? This is not a true EMQ as there may be > 1 correct answer.

Option list.

A

inform her that the risk of being a carrier in this pregnancy is 25%

B

IAP without screening

C

IAP if screening shows bowel colonisation, but not if it is absent

D

IAP if screening shows genital tract colonisation, but not if it is absent

E

IAP if screening shows urinary tract colonisation, but not if it is absent

F

IAP if screening shows any GBS colonisation

G

screening for GBS at around 36 weeks, with IAP if testing is +ve

Question 12.         

What management options should be offered to a pregnant woman with a history of GBS carriage in a previous pregnancy but no EOGBSD or LOGBSD and no evidence of it in the current pregnancy? This is not a true EMQ as there may be > 1 correct answer.

Option list.

A

inform her that the risk of being a carrier in this pregnancy is 25%

B

IAP without screening

C

IAP if screening shows bowel colonisation, but not if it is absent

D

IAP if screening shows genital tract colonisation, but not if it is absent

E

IAP if screening shows urinary tract colonisation, but not if it is absent

F

IAP if screening shows any GBS colonisation

G

screening for GBS at around 36 weeks, with IAP if testing is +ve

Question 13.         

Which, if any, of the following statements are true in relation to screening for GBS in pregnancy?

Option list.

A

screening should be done 1-3 weeks before the ADD

B

screening should be done 2-4 weeks before the ADD

C

screening should be done 3-5 weeks before the ADD

D

screening should be done 4-6 weeks before the ADD

E

screening should be done 4-6 weeks before the ADD

F

screening should not be offered

Question 14.         

Which, if any, of the following statements is true in relation to screening for GBS in twin pregnancy?

Option list.

A

screening should be done 1-3 weeks before the ADD

B

screening should be done 2-4 weeks before the ADD

C

screening should be done 3-5 weeks before the ADD

D

screening should be done 4-6 weeks before the ADD

E

screening should be done 4-6 weeks before the ADD

F

screening should not be offered

Question 15.         

Which, if any, of the following statements is true in relation to screening for GBS?

Option list.

A

oral, rectal & vaginal swabs should be taken and an MSU

B

rectal & vaginal swabs should be taken

C

rectal & vaginal swabs should be taken and an MSU

D

a single swab can be used, swabbing orally then vaginally, then rectally

E

a single swab can be used, swabbing vaginally, then rectally

F

none of the above

Question 16.         

Which, if any, of the following statements are true in relation to transport of swabs for GBS?

Option list.

A

swabs should be transported to the laboratory ASAP

B

swabs should be transported to the laboratory refrigerated

C

swabs should be transported in a non-nutrient medium

D

sways should be transported in a nutrient-enhanced medium

E

Amies medium is suitable

F

Stuart medium is suitable

G

blood agar is suitable

Question 17.         

Which, if any, of the following statements are true in relation to processing of swabs for GBS?

Option list.

A

processing should be done ASAP

B

specimens should be refrigerated if processing cannot be done immediately

C

specimens should be stored at a temperature lower than –10oC  if processing cannot be done immediately

D

testing should be done using an enriched culture medium

E

testing should be done using a cultured medium

Question 18.         

Which, if any, of the following statements is true in relation to screening for GBS in twin pregnancy?

Option list.

A

screening should be done 30-32 weeks

B

screening should be done 31-33 weeks

C

screening should be done 32-34 weeks

D

screening should be done 33-35 weeks

E

screening should be done 34-36 weeks

E

screening should be done 35-37 weeks

E

screening should be done 36-38 weeks

F

screening should not be offered

Question 19.         

What does GTG say about screening for GBS on maternal request when there are no factors indicating increased risk?

Option list.

Option list.

A

maternal request is not an indication for screening

B

refer her to a hospital with a policy of offering screening on request

C

screening should be offered it still desired after explanation of the pros and cons and that it is not recommended

D

the request should be respected and screening offered

E

none of the above

Question 20.         

Which, if any, of the following would be appropriate management of a pregnant woman with GBS UTI?

Option list.

A

offer IAP

B

repeat the MSU

C

treat the UTI and arrange appropriate follow-up and GBS screening

D

treat the UTI, arrange appropriate follow-up and offer IAP

E

none of the above

Question 21.         

What advice does ACOG797 give about the use of clindamycin for GBS urinary tract infection.

Option list.

A

it should be the 1st. choice for treatment in those who are not allergic to it

B

it should be the 1st. choice for treatment in those who are allergic to penicillin

C

it should only be used intravenously for treatment of urinary tract infection

D

it should not be used for urinary tract infection

E

it should be used, like other antibiotics, based on the sensitivity of the infecting organism

Question 22.         

Which, if any, of the following would be appropriate management of a pregnant woman with GBS on a vaginal or rectal swab?

Option list.

A

offer IAP

B

repeat the swab

C

treat the infection and arrange appropriate follow-up and GBS screening

D

treat the infection, arrange appropriate follow-up and offer IAP

E

none of the above

Question 23.         

Which, if any, of the following statements are correct about induction of labour in women who are carriers of GBS?

Option list.

A

amniotomy is the preferred method

B

membrane sweeping is contra-indicated

C

vaginal PGE2 is the preferred method 

D

an i.v. antibiotic should be given with the start of the process

E

none of the above

Question 24.         

A woman with no risk factors for GBS goes into preterm labour. Which, if any, of the following statements are correct?

Option list.

A

GBS screening should be done with PCR or other ‘near-patient’ test

B

IAP should be offered

C

IAP should not be offered unless clinical evidence of infection appears

D

tocolytics should be offered

E

none of the above

Question 25.         

A woman with no risk factors for GBS has PPROM. Which, if any, of the following statements are correct?

Option list.

A

GBS screening should be done

B

IAP should be offered immediately

C

IAP should be offered when labour ensues or is induced

D

IOL should be offered

E

none of the above

Question 26.         

In which of the following situations is polymerase chain reaction or other ‘near-patient’ testing recommended in relation to GBS?

Option list.

A

women admitted with SROM whose GBS status is unknown

B

women treated for GBS infection in pregnancy admitted in preterm labour

C

women for whom C section is planned but go into premature labour

D

unbooked patients admitted in labour

E

unbooked patients admitted with SROM

F

none of the above

Question 27.         

A woman who is a known GBS carrier wishes to use a birthing pool. Which, if any, of the following statements are correct?

Option list.

A

use of a birthing pool is contraindicated

B

use of a birthing pool is not contraindicated

C

use of a birthing pool is not contraindicated so long as appropriate IAP is given

D

use of a birthing pool is acceptable, but the water must contain an antiseptic in a concentration known to kill > 99.9% of all known bacteria and viruses

E

tell her not to be stupid

F

none of the above

Question 28.         

A woman in labour has a temperature of 38.40C. Which of the following is correct?

Option list.

A

IAP should be offered

B

amoxicillin should be offered unless she is allergic to penicillin

C

amoxicillin + metronidazole should be offered unless she is allergic to penicillin

D

a cephalosporin should be offered

E

a cephalosporin + metronidazole should be offered

F

none of the above

Question 29.         

Which, if any, of the following statements are true in relation to GBS and prematurity.

Option list.

A

IAP should be offered

B

premature babies are less likely to develop EOGBSD than term babies

C

premature babies are just as likely to develop EOGBSD as term babies

D

premature babies are four times more likely to develop EOGBSD than term babies

E

premature babies are ten times more likely to develop EOGBSD  than term babies

F

premature babies are less likely to die of EOGBSD than term babies

G

premature babies are just as likely to die of EOGBSD as term babies

H

premature babies are four times more likely to die of EOGBSD than term babies

I

premature babies are ten times more likely to die of EOGBSD than term babies

Question 30.         

A GBS carrier has PPROM. Which, if any, of the following statements are correct?

Option list.

A

IAP should be offered immediately

B

IAP should be offered when labour starts

C

IAP should not be offered

D

erythromycin should be offered immediately if not contraindicated

E

erythromycin should be offered when labour starts if not contraindicated

F

erythromycin should not be offered

G

IOL should be offered ASAP

H

IOL should not be offered

I

labour should be augmented as soon as contractions start

Question 31.         

A GBS carrier goes into premature labour Which, if any, of the following statements are correct?

Option list.

A

IAP should be offered immediately

B

IAP should be offered when contractions start

C

IAP should not be offered

D

augmentation of labour should be offered ASAP

E

augmentation of labour  should not be offered

F

labour should be augmented as soon as contractions start

Question 32.         

A woman whose GBS carrier status is negative has PPROM. Which, if any, of the following statements are correct?

Option list.

A

expectant management for up to 24 hours is acceptable

B

expectant management for up to 48 hours is acceptable

C

IAP should be offered immediately

D

IAP should be offered when contractions start

E

IAP should not be offered

F

immediate IOL is acceptable

G

IOL should not be delayed > 24 hours if labour does not ensue

H

IOL should not be offered

I

labour should be augmented as soon as contractions start

Question 33.         

A woman whose GBS carrier status is unknown has PPROM. Which, if any, of the following statements are correct?

Option list.

A

expectant management for up to 24 hours is acceptable

B

expectant management for up to 48 hours is acceptable

C

IAP should be offered immediately

D

IAP should be offered when contractions start

E

IAP should not be offered

F

immediate IOL is acceptable

G

IOL should not be delayed > 24 hours if labour does not ensue

H

IOL should not be offered

I

labour should be augmented as soon as contractions start

Question 34.         

A GBS carrier has SROM at 38 weeks. Which, if any, of the following statements are correct?

Option list.

A

IAP should be offered immediately

B

IAP should be offered when contractions start

C

IAP should not be offered

D

IOL should be offered ASAP

E

IOL should not be offered

F

labour should be augmented as soon as contractions start

Question 35.         

A GBS carrier goes into labour at 38 weeks. Which, if any, of the following statements are correct?

Option list.

A

IAP should be offered immediately

B

IAP should be offered when contractions start

C

IAP should not be offered

D

augmentation of labour should be offered ASAP

E

augmentation of labour  should not be offered

F

labour should be augmented as soon as contractions start

Question 36.         

A woman whose GBS carrier status is negative has SROM at 38 weeks. Which, if any, of the following statements are correct?

Option list.

A

expectant management for up to 24 hours is acceptable

B

expectant management for up to 48 hours is acceptable

C

IAP should be offered immediately

D

IAP should be offered when contractions start

E

IAP should not be offered

F

immediate IOL is acceptable

G

IOL should not be delayed > 24 hours if labour does not ensue

H

IOL should not be offered

I

labour should be augmented as soon as contractions start

Question 37.         

A woman whose GBS carrier status is unknown has SROM at 38 weeks. Which, if any, of the following statements are correct?

Option list.

A

expectant management for up to 24 hours is acceptable

B

expectant management for up to 48 hours is acceptable

C

IAP should be offered immediately

D

IAP should be offered when contractions start

E

IAP should not be offered

F

immediate IOL is acceptable

G

IOL should not be delayed > 24 hours if labour does not ensue

H

IOL should not be offered

I

labour should be augmented as soon as contractions start

Question 38.         

What vaginal cleansing is recommended in GTG36 for women known to be colonised with GBS to reduce fetal transmission in labour and delivery?

Option list.

A

aqueous chlorhexidine 1%

B

povidone-iodine 1%

C

acetic acid 1%

D

aqueous bicarbonate of soda 1%

E

none of the above.

Question 39.         

Which antibiotic / antibiotic combination is the 1st. choice for IAP, assuming no allergy or other contraindication?

Option list.

A

a cephalosporin

B

a cephalosporin + clavulanic acid

C

a cephalosporin + metronidazole

D

a cephalosporin + streptomycin

E

amoxicillin

F

amoxicillin + clavulanic acid

G

amoxicillin + metronidazole

H

amoxicillin + streptomycin

I

benzylpenicillin

J

benzylpenicillin + clavulanic acid

K

benzylpenicillin + metronidazole

L

benzylpenicillin + streptomycin

M

tetracycline

N

tetracycline + clavulanic acid

O

tetracycline + metronidazole

P

tetracycline + streptomycin

Q

none of the above

Question 40.         

Which antibiotic / antibiotic combination is the 2nd? choice for IAP, assuming no allergy or other contraindication?

Option list.

A

a cephalosporin

B

a cephalosporin + clavulanic acid

C

a cephalosporin + metronidazole

D

a cephalosporin + streptomycin

E

amoxicillin

F

amoxicillin + clavulanic acid

G

amoxicillin + metronidazole

H

amoxicillin + streptomycin

I

benzylpenicillin

J

benzylpenicillin + clavulanic acid

K

benzylpenicillin + metronidazole

L

benzylpenicillin + streptomycin

M

tetracycline

N

tetracycline + clavulanic acid

O

tetracycline + metronidazole

P

tetracycline + streptomycin

Q

none of the above

Question 41.         

How should babies at risk of EOGBSD whose mothers have had adequate IAP be monitored for signs of infection?

Option list.

A

routine monitoring is all that is required

B

they should be checked at birth for signs of infection

C

their vital signs should be checked hourly for 12 hours

D

their vital signs should be checked hourly for 24 hours

E

their vital signs should be checked hourly for 48 hours

F

their vital signs should be checked 4 hourly for 12 hours

G

their vital signs should be checked 4 hourly for 24 hours

H

their vital signs should be checked 4 hourly for 48 hours

I

their vital signs should be checked at 0, 1 & 2 hours, then hourly until 12 hours

J

their vital signs should be checked at 0, 1 & 2 hours then hourly until 24 hours

K

their vital signs should be checked at 0, 1 & 2 hours, then hourly until 48 hours

L

their vital signs should be checked at 0, 1 & 2 hours, then 2 hourly until 12 hours

M

their vital signs should be checked at 0, 1 & 2 hours, then 2 hourly until 24 hours

N

their vital signs should be checked at 0, 1 & 2 hours, then 2 hourly until 48 hours

O

their vital signs should be checked at 0, 1 & 2 hours, then 4 hourly until 12 hours

P

their vital signs should be checked at 0, 1 & 2 hours, then 4 hourly until 24 hours

Q

their vital signs should be checked at 0, 1 & 2 hours, then 4 hourly until 48 hours

R

none of the above

Question 42.         

What antibiotic treatment should be provided for babies with signs of EOGBSD?

Option list.

A

benzylpenicillin within 1 hour of birth

B

benzylpenicillin within 4 hours of birth

C

benzylpenicillin + gentamycin within 1 hour of birth

D

benzylpenicillin + gentamycin within 4 hours of birth

E

benzylpenicillin  + metronidazole within 1 hour of birth

F

benzylpenicillin  + metronidazole within 4 hours of birth

G

benzylpenicillin + streptomycin within 1 hour of birth

H

benzylpenicillin  + streptomycin within 4 hours of birth

I

none of the above

Question 43.         

A woman is noted to be pyrexial in labour, temperature = 38.4OC. What antibiotic therapy, if any, should be provided, assuming she has no drug allergies?

Option list.

A

benzyl penicillin

B

amoxicillin

C

amoxicillin + clavulanic acid

D

broad spectrum antibiotic that covers GBS and is in accordance with the local antibiotic advice.

E

a cephalosporin

F

clindamycin

G

quinolone antibiotic that covers GBS and is in accordance with the local antibiotic advice.

H

none of the above

Question 44.         

A woman is found to have GBS colonisation but declines IAP. Which, if any, of the following are appropriate?

Option list.

A

advise her that she should stay in hospital for at least 48 hours so the baby can be monitored

B

ask her to transfer to another hospital if she won’t take your advice re the GBS protocol

C

explain the rationale of the policy relating to IAP and maternal GBS colonisation

D

get the hospital lawyer to ask the Court of Protection to appoint a Deputy to authorise IAP.

E

give her a good slapping

F

tell her to think about the baby, not herself

Question 45.         

What possible adverse effects of IAP are discussed in GTG36?

Option list.

A

anaphylaxis

B

antibiotic resistance

C

disturbance of neonatal microbiome

D

NEC

E

asthma in children

F

cerebral palsy in children

G

impaired functional development in children

H

inflammatory bowel disease in children

I

schizophrenia in adolescents

Question 46.         

What advice should be given about breastfeeding?

Option list.

A

it should be encouraged

B

it should be encouraged but withheld during administration of IAP

C

it should be encouraged but withheld during administration of IAP and the week after

D

it is contraindicated

E

none of the above.

 

39.         Retinoids and pregnancy.

Retinoids & pregnancy.

I think the questions you are likely to be asked will come from the TOG article by Browne et al and are covered by the associated TOG CPD questions. Hannah Browne, Gerald Mason and Thomas Tang: “Retinoids and pregnancy”. TOG. 2014. Volume16, Issue1, Pages 7-11.

The article and CPD questions are open access and reproduced here.

With regard to isotretinoin,

1.     its mode of action is to reduce sebum secretion.                                                      True False

2.     it is used as a first-line treatment for acne.                                                                True False

3.     it has an elimination half-life of less than 10 hours.                                                 True False

4.     the dose prescribed is adjusted according to the patient’s weight.                                   True False

5.     the estimated pregnancy rate while on treatment is around 1%.                                          True False

Regarding side effects of retinoids (such as isotretinoin) including their teratogenicity,

6.     mood disturbance is well documented.                                                                      True False

7.     derivatives of the mesonephric duct are recognised malformations.                     True False

8.     limb deformities are common.                                                                                     True False

9.     their use in pregnancy is associated with ear abnormalities.                                     True False

With regard to the incidence of teratogenic effects of isotretinoin,

10.   30% of affected fetuses have been reported to perform poorly in neuropsychological tests.

11.   approximately half of fetuses exposed to them suffer from mental retardation.             True False

12.   about a third of fetuses exposed to them have retinoid specific fetal malformations.            True False

Concerning the pregnancy prevention programme in those being placed on isotretinoin;

13.   the programme was launched in 2005 in the UK.                                                      True False

14.   contraception should be used for 1 month prior to and 2 months following treatment.

                                                                                                                                                  True False

15.   pregnancy tests should be taken monthly throughout treatment.                                           True False

16.   exerts its teratogenic effect through a mechanism that does not significantly affect vitamin A levels.                                                                                                                          True False

17.   affects the development of the branchial arches by effecting haemopexin signalling.     True False

18.   is associated with a miscarriage of over 20% when used in the first trimester. True False

Concerning retinoid embryopathy,

19.   topical application is not associated with an increased risk.                                                 True False

20.   the most common malformations are those of the musculoskeletal system.                   True False

Breastfeeding does not feature in the TOG questions, so I have added it..

Retinoid use is safe during breastfeeding.                                                                          True False

 

40.         Caldicott guardian.

Question 1.

Option List

A

it is a large lizard, unique to the Galapagos Islands

B

it is the Trust Board member responsible for child safeguarding procedures

C

it is the Trust Board member responsible for complaint procedures

D

it is the person within a Trust responsible for patient confidentiality in relation to information

E

it is the person within a Trust responsible for dealing with bullying

Question 2.

Lead-in

The Caldicott Report identified 6 basic principles. What are they?

Option list.

There is none. Imagine that there is information about you stored on the computers of the local NHS Trust. What conditions would you want to lay down about sharing of that information within the Trust, with other NHS organisations and with non-NHS organisations?

Question 3.

Lead-in

The Caldicott Report made numerous recommendations. Which was particularly important for major NHS organisations such as Trusts?

Option List

A.       

the need to appoint a Caldicott Guardian

B.       

the need to create a Caldicott Register

C.       

the need to create a Caldicott Police Department

D.      

the need to create a link between the Caldicott Department and the DOH

E.       

none of the above.

Question 4.

What is the definition of the key role deriving from the answer to question 3?

Option List

There is none lest it give you the answer to question 3!

 

41.         Tetracycline and pregnancy.

Question 47.         

Option list.

A

tetracyclines are β-lactam antibiotics

B

tetracyclines inhibit bacterial protein synthesis

C

tetracyclines are bactericidal

D

tetracyclines bind strongly to calcium and form stable complexes in bone

E

tetracyclines bind strongly to fetal bone and teeth

F

there is evidence that tetracyclines are teratogenic

G

tetracyclines are contraindicated in pregnancy

H

tetracyclines are contraindicated during breastfeeding

I

tetracyclines taken in the 1st. trimester are grounds for offering TOP

J

tetracyclines may cause fatal maternal hepatic damage

 

 

 

 


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