Monday 28 November 2022

Tutorial 28th. November 2022

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24

Role-play. PMB

25

EMQ. Kangaroo care

26

EMQ. Kell antibodies

27

EMQ. Parvovirus

28

EMQ. Ulipristal

29

EMQ. ‘CAESAR’ trial

 

24.         Role-play. PMB.

Candidate’s Instructions.

You are an SpR in the “one-stop” PMB clinic. Mary Smith, 55 years old, has been referred by her General Practitioner. She has had some bleeding since the menopause.

Your task is to take an appropriate history and advise her about the investigations you feel are appropriate and why.

 

25.         EMQ. Kangaroo care.

These are not true EMQs as there may be more than one answer. I do this to compress several questions into one to reduce the amount of typing and the paper and ink needed for printing. The wording will indicate whether there is one or more than one answer.

Question  1.           Which, if any, of the following are true in relation to kangaroo care?

Option list.

A.

skin-to-skin contact between mother and baby is a key component

B.

rooming-in is a key component

C.

exclusive breastfeeding is a key component

D.

carrying the baby in a sling anterior to the maternal chest is a key component

E.

carrying the baby in a sling on the mother’s back is a key component

F.

carrying the baby in a sling on the mother’s chest or back is a key component

G.

carrying the baby in a sling with skin-to-skin contact with the mother is a key component

Question  2.           Which, if any,  of the following are proven benefits of Kc?

Option list.

A.

neonatal mortality

B.

neonatal morbidity

C.

breastfeeding rates

D.

head circumference growth

E.

hypothermia

F.

mother-baby bonding

G.

necrotising enterocolitis

H.

neonatal intra-ventricular haemorrhage

I.

neonatal sepsis

J.

neonatal weight gain

K.

postnatal depression

L.

psychomotor development at 12 months

 

26.         EMQ. Kell antibodies.

Abbreviations.

OD450:      spectrophotometric measurement of deviation in optical density at wavelength 450 nm.

FMM:         feto-maternal medicine.

HDFN:        haemolytic disease of the fetus and newborn.

MCAPSV:   middle cerebral artery peak systolic velocity.

RBC:           red blood cell.

Scenario 1.         Which of the following alloantibodies is the most common cause of significant HDFN?

Option list.

A

anti-D

B

anti-C

C

anti-c

D

anti-e

E

Duffy: Fya

F

Duffy: Fyb

G

Kell

H

Kidd: Jka

I

Kidd: Jkb

Scenario 2.         What is the 2nd. most common cause of significant HDFN?

Scenario 3.         What is the 3rd. most common cause of significant HDFN?

Scenario 4.         Which of the following is true in relation to the Kell antigen?

Option list.

A

it is named after Mrs. Kelleher who was found to have antibodies to it in 1946

B

it is named after Gene Kelly, the American actor, dancer and singer as the research group who found the antigen were big fans

C

there are > 50 significant variants of the Kell antigen

D

Kell antibodies are mainly IgA

E

Kell antibodies are mainly IgM

F

none of the above

Scenario 5.         What proportion of the Caucasian population is K +ve?

Option list.

A

1%

B

5%

C

9%

D

15%

E

25%

F

33%

G

57%

H

none of the above

Scenario 6.         Can the Kell antigen be detected using cffDNA in maternal serum.  True / False.

Scenario 7.         Anti-K is thought to occur mainly as a result of feto-maternal transfusion of Kell +ve

cells during pregnancy and delivery. True / False.

Scenario 8.         Kell HDFN resulting from transfusion of Kell +ve blood is thought to produce more

severe HDFN than that resulting from feto-maternal transfusion. True / False.

Scenario 9.         Which of the following statements is true in relation to anti-Kell antibodies in a Kell-

negative mother with a Kell +ve pregnancy?

Option list.

A

HDND is mainly due to haemolysis of fetal RBC

B

HDND is mainly due to haemolysis of fetal & neonatal RBC

C

HDND is mainly due to haemolysis of neonatal RBC

D

HDND is mainly due to sequestration of fetal RBC

E

HDND is mainly due to sequestration of fetal & neonatal RBC

F

HDND is mainly due to sequestration of neonatal RBC

G

HDND is mainly due to suppression of fetal erythroid progenitor cells

H

HDND is mainly due to suppression of neonatal erythroid progenitor cells

I

none of the above

Scenario 10.      Which of the following statements is true in relation to antenatal detection of HDFN

due to anti-K antibodies?

Option list.

A

the threshold for significant HDFN is a titre of 1 in 4

B

the threshold for significant HDFN is a titre of 1 in 8

C

the threshold for significant HDFN is a titre of 1 in 16

D

the threshold for significant HDFN is a titre of 1 in 32

E

the threshold for significant HDFN is a titre of 1 in 64

F

the threshold for significant HDFN is a titre of 1 in 128

G

the threshold for significant HDFN is a titre of 1 in 256

H

none of the above

Scenario 11.      Which of the following statements is true in relation to antenatal detection of HDFN

due to anti-K antibodies?

Option list.

A

the threshold for significant HDFN is a level > 2 iu/L.

B

the threshold for significant HDFN is a level > 4 iu/L.

C

the threshold for significant HDFN is a level > 7.5 iu/L.

D

the threshold for significant HDFN is a level > 10 iu/L.

E

the threshold for significant HDFN is a level > 15 iu/L.

F

the threshold for significant HDFN is a level > 25 iu/L.

G

the threshold for significant HDFN is any level if anti-E is also present.

H

none of the above

Scenario 12.      Which, if any, of the following statements are true in relation to referral to a FMM

expert when Kell antibodies are detected?

Option list.

A

the threshold for referral is a level of anti-K > 2 iu/L.

B

the threshold for referral is a level of anti-K > 4 iu/L.

C

the threshold for referral is a level of anti-K > 7.5 iu/L.

D

the threshold for referral is a level of anti-K > 10 iu/L.

E

the threshold for referral is a level of anti-K > 15 iu/L.

F

the threshold for referral is a level of anti-K > 25 iu/L.

G

the threshold for referral is any level of anti-K.

H

the threshold for referral is any level of anti-K if anti-E is also present.

I

none of the above

Scenario 13.      Which of the following statements is true in relation to the threshold for antenatal

diagnosis of significant HDFN due to anti-K when using measurement of MCAPSV?

Option list.

A

MoM > 1.25

B

MoM > 1.50

C

MoM > 1.75

D

MoM > 2.00

E

MoM > 2.50

F

MoM > 3.00

G

none of the above

Scenario 14.      Which of the following statements is true in relation to the threshold for antenatal

diagnosis of significant HDFN due to anti-K when using measurement of ∆OD450?

Option list.

A

MoM > 1.25

B

MoM > 1.50

C

MoM > 1.75

D

MoM > 2.00

E

MoM > 2.50

F

MoM > 3.00

G

none of the above

Scenario 15.      Which, if any, of the following statements are true in relation to the numbers of

reticulocytes in cord blood in moderate to severe HDFN due to anti-K antibodies?

Option list.

A

the numbers are decreased

B

the numbers are increased

C

the numbers are normal

D

none of the above

Scenario 16.      Which, if any, of the following statements are true in relation to the numbers of

erythroblasts in cord blood in moderate to severe HDFN due to anti-K antibodies?

Option list.

A

the numbers are decreased

B

the numbers are increased

C

the numbers are normal

D

none of the above

Scenario 17.      Which, if any, of the following statements are true in relation to the level of bilirubin

in cord blood in moderate to severe HDFN due to anti-K antibodies?

Option list.

A

it is decreased

B

it is increased

C

it is greatly increased

D

none of the above

Scenario 18.      Which, if any, of the following are true in relation to King Henry VIII and Kell?

Option list.

A

Kell may have been the cause of his subfertility

B

He may have had the McLeod syndrome

C

He may have inherited the Kell antigen from Jacquetta Woodville

D

The Kell antigen may have explained his passion for jousting

E

The Kell antigen may have explained his passion for extramarital dalliance

 

The TOG questions for the Gajjar article can be found  here.

They are open access, which allows me to reproduce them.

Regarding Kell alloimmunisation in pregnancy,

1      the amniotic fluid bilirubin level correlates well with the degree of fetal anaemia.         True / False

2      previous obstetric history does not reliably predict outcome.                                True / False

3      the incidence in the obstetric population is approximately 1–2 per 1000.                         True / False

4      prophylaxis is available.                                                                                                   True / False

5      the relationship between fetal middle cerebral artery peak systolic velocity (MCA-PSV) and haemoglobin concentration is poor.                                                                             True / False

6      anti-Kell antibodies cause fetal anaemia via the suppression of erythropoiesis rather than red cell destruction.                                                                                                                   True / False

With regard to maternal anti-Kell antibody screening,

7      if the father of the fetus is Kell antigen positive, the fetus is likely to be affected with severe HDFN.                                                                                                                                       True / False

8      where the father is heterozygous for Kell, there is a 50% chance of the fetus carrying the Kell antigen on its fetal red cells.                                                                               True / False

9      anti-Kell antibodies stimulated by transfusion are known to affect the fetus to the same degree as those stimulated from a previous pregnancy.                                                                        True / False

Transfusion seems to produce less severe disease.

10    where the critical titre of anti-Kell antibodies has been reached in the maternal serum, amniocentesis for spectral analysis of amniotic fluid is a reliable means of establishing the degree and severity of fetal anaemia.                                                                           True / False

 

27.         EMQ. Parvovirus.

Abbreviations.

PvB19:          parvovirus B19

PvIgG:           parvovirus B19 IgG

PvIgM:          parvovirus B19 IgM

Option list.

There are no option lists apart from the last few questions. Make up your own answers! In the exam it is best if you decide the answer without reference to the option list and then identify it on the list.

Scenario 1.               What type of virus is parvovirus?

Scenario 2.               Is the title B19 something to do with the American B19 bomber, its potentially devastating bomb load and the comparably devastating consequences of the parvovirus on human erythroid cell precursors?

Scenario 3.               PVB19 in the UK occurs in mini-epidemics at 3 to 4-year intervals, usually during the summer.

Scenario 4.               Which animal acts as the main reservoir for infection?

Scenario 5.               What is the approximate incidence of maternal parvovirus infection in the UK?

Scenario 6.               What percentage of UK adults are immune to parvovirus infection?

Scenario 7.               What names are given to acute infection in the human?

Scenario 8.               What is the incubation period for parvovirus infection?

Scenario 9.               What is the duration of infectivity for parvovirus infection?

Scenario 10.           What are the usual symptoms of parvovirus infection in the adult?

Scenario 11.           What is the incidence of parvovirus infection in pregnancy?

Scenario 12.           How is recent infection diagnosed?

Scenario 13.           How long does PvIgM persist and why is this important?

Scenario 14.           What is the rate of vertical transmission of parvovirus infection?

Scenario 15.           Are women with parvovirus infection who are asymptomatic less likely to pass the virus to their fetuses?

Scenario 16.           To what degree is parvovirus infection teratogenic?

Scenario 17.           What proportion of pregnancies infected with parvovirus are lost?

Scenario 18.           What is the timescale for the onset of hydrops?

Scenario 19.           Laboratories are advised to retain bloods obtained at booking for at least 2 years for possible future reference. True or false?

Scenario 20.           What ultrasound features would trigger consideration of cordocentesis?

Scenario 21.           Must suspected parvovirus infection be notified to the authorities?

Scenario 22.           Possible parvovirus infection does not need to be investigated after 20 week’s gestation. True or false?

Scenario 23.           If serum is sent to the laboratory from a woman with a rash in pregnancy for screening for rubella, the laboratory should automatically test for parvovirus infection too?

Scenario 24.           A woman attends the pre-pregnancy counselling clinic as she is planning her first pregnancy. She wants to know what screening for parvovirus is recommended.

Scenario 25.           A pregnant woman has had a significant contact with a child with PARV infection. She has had urgent tests for PvIgG and PvIgM. Both results were -ve. Which of the options best fits the advice she should be given?

Option list.

1

the tests show acute parvovirus infection

2

the tests show chronic parvovirus infection

3

the tests show that she has not had PARV infection and is susceptible to it

4

the tests show no evidence of PARV infection but she should have repeat tests in 1 month

5

the tests show old PARV infection and immunity

6

the tests show recent PARV infection

7

none of the above

Scenario 26.           A pregnant woman has had a significant contact with a child with PARV infection. She has had urgent tests for PvIgG and PvIgM. Both results were +ve. Which of the options best fits the advice she should be given?

Option list.

1

the tests show acute parvovirus infection

2

the tests show chronic parvovirus infection

3

the tests show that she has not had PARV infection and is susceptible to it

4

the tests show no evidence of PARV infection but she should have repeat tests in 1 month

5

the tests show old PARV infection and immunity

6

the tests show recent PARV infection

7

none of the above

Scenario 27.           A pregnant woman has had a significant contact with a child with PARV infection. She has had urgent tests for PvIgG and PvIgM. The results were PvIgG +ve and PvIgM -ve. Which of the options best fits the advice she should be given?

Option list.

1

the tests show acute parvovirus infection

2

the tests show chronic parvovirus infection

3

the tests show that she has not had PARV infection and is susceptible to it

4

the tests show no evidence of PARV infection but she should have repeat tests in 1 month

5

the tests show old PARV infection and immunity

6

the tests show recent PARV infection

7

none of the above

Scenario 28.           A pregnant woman has had a significant contact with a child with PARV infection. She has had urgent tests for PvIgG and PvIgM. The results were PvIgG -ve and PvIgM +ve. Which of the options best fits the advice she should be given?

Option list.

1

the tests show acute parvovirus infection

2

the tests show chronic parvovirus infection

3

the tests show that she has not had PARV infection and is susceptible to it

4

the tests show no evidence of PARV infection but she should have repeat tests in 1 month

5

the tests show old PARV infection and immunity

6

the tests show recent PARV infection

7

none of the above

Scenario 29.           A pregnant woman has had a significant contact with a child with PARV infection. What prophylaxis should be offered?

Option list.

1

acyclovir orally

2

acyclovir i.m.

3

acyclovir i.v.

4

hand-washing and avoiding small children

5

i.v. hyperimmune globulin

6

PVV vaccine

7

there is no proven prophylaxis

 

 

 

 

28.         EMQ. Ulipristal.

Abbreviations.

EC:              emergency contraception

eMC:          electronic medicines compendium

CYP450:     cytochrome P450

UPA            ulipristal acetate

Question 1.            What type of drug is ulipristal?

Question 2.            How does ulipristal prevent conception as an emergency contraceptive?

Question 3.            How is ulipristal broken down / excreted?

Question 4.            What is the half-life of ulipristal?

Question 5.             Which drug (erythromycin, phenobarbitone, valium)  may prolong the half-life of ulipristal?

Question 6.             Which drugs may reduce the half-life of ulipristal? There is no option list. Just write down as many drugs as you can think of that induce the CYP450 enzymes.

Question 7.            What is the main use of ulipristal?

Question 8.            What is the dose of ulipristal?

Question 9.            What time-scale applies to the licensed use of ulipristal?

Question 10.         What contraceptive advice is given to those using ulipristal?

Question 11.         What advice is given to women who are breast-feeding?

Question 12.         Can treatment with ulipristal be repeated within 1 month?

Question 13.         Which medical conditions are contraindications to ullipristal use ? These are not on the option list.

Question 14.         What is the current situation re prescribing ulipristal? Write the key facts.

 

29.         SBA. ‘CAESAR’ trial.

Abbreviations.

ECV:           external cephalic version.

SSI:             surgical site infection.

Question 1.     What was the CAESAR trial? Which, if any, of the following statements are true?

Statements

A

a prospective, cohort study

B

a randomised, controlled trial

C

a comparison of selected techniques used during Caesarean section

D

a study of the risks of Caesarean section on maternal request without medical grounds

E

a study of the outcomes of C section performed after failed instrumental delivery

Question 2.     Where did the questions addressed by the trial come from?

Option list

A

the RCOG council

B

the RCOG exam committee

C

a survey of UK obstetricians asking what questions they would like to have answered

D

Dr. Johnstone, Consultant Obstetrician, Falkirk

E

National Childbirth Trust

Question 3.        The questionnaire also asked about the issues that the respondents would like to see addressed in a research programme. What issues were include in the CAESER trial?

Statements

A

outcome of C. section depending on aqueous versus alcohol-based skin preparation

B

cord traction versus manual removal of the placenta

C

digital versus ‘swab on a holder’ exploration of the uterine cavity to exclude RPOC

D

Joel-Cohen compared with Pfannenstiel incision

E

elective C. section at 38 versus 39 weeks

F

elective C. section with staff wearing masks versus not wearing masks

G

prophylactic antibiotics versus no prophylactic antibiotics

H

pre-op vaginal antiseptic “painting” versus none

I

blunt v. sharp opening of the lower segment

J

manual versus forceps delivery of the fetal head in cephalic presentations

K

single v double closure of the lower segment

L

closure v non-closure of parietal & pelvic peritoneum

M

liberal v restricted use of pelvic drains

N

glue v subcuticular suturing of the skin

O

none of the above

Question 4.     Which of the following statements is true of the definition of the 1ry. outcome?

Option list

A

use of antibiotics for maternal infectious morbidity during the hospital stay

B

use of antibiotics for maternal infectious morbidity during the 1st. six weeks

C

duration of postnatal hospital stay

D

abdominal and pelvic pain as measured on an analogue scale at 6 weeks

E

none of the above.

Question 5.        Which, if any, of the following describe the 2ry. outcomes? > 1 may be correct.

Statements:

A

additional treatments to the abdominal wound

B

haematoma formation

C

pain

D

breast feeding at discharge

E

breast feeding at 6 weeks

F

unexpected maternal morbidity

G

postnatal depression at 6 weeks

H

puerperal psychosis

Question 6.     Which if any of the following statements are true of the findings of the study?

Statements

A

there were no significant differences for any outcome

B

there was more endometritis after non-closure of the pelvic peritoneum

C

there was more 2ry. bleeding after interrupted-suture closure of the lower segment

D

there was more evidence of pelvic infection with liberal use of pelvic drains

E

none of the above.

Question 7.     When does the WHO recommend that prophylactic antibiotics be given at C section.

Option list

A

4 hours before the incision

B

2 hours before the incision

C

1 hour before the incision

D

with the incision

E

just before the incision

Question 8.        What did the paper by Sommerstein et al of December 2020 add to the debate on timing of administration of prophylactic antibiotics at C section?

Option list.

A

prophylactic antibiotics are most effective if given 1 hour before incision

B

prophylactic antibiotics are most effective if given ½ hour before incision

C

prophylactic antibiotics are most effective if given at the time of incision

D

prophylactic antibiotics are less effective if given after cord clamping

E

prophylactic antibiotics are equally effective if given after cord clamping

F

prophylactic antibiotics are most effective if given at incision and continued for 48 hours

G

none of the above