|
19 |
Role-play. Androgen insensitivity
syndrome |
|
20 |
Role-play. Farmer’s wife at booking |
|
21 |
Viva. Diathermy |
|
22 |
Viva. Cochrane review |
|
23 |
EMQ.
Folic acid fortification of flour |
19. Role-play.
Androgen insensitivity syndrome.
The patient is
Anastasia Johnstone. She is 17 years old. She attended the gynaecology clinic 1
month ago with primary amenorrhoea. Clinical examination showed an apparently
normal young woman with normal breast development but absent pubic and axillary
hair. The external genitalia appeared normal. Vaginal examination was not
attempted.
She has come today
for the results of an ultrasound scan and blood tests. The scan shows absence
of the uterus. There are no ovaries in the pelvis. There are bilateral groin
masses. The karyotype is 46XY.
Your tasks are to
explain the results and their implications and to answer her questions.
20. Role-play.
Farmer’s wife at booking.
Candidate’s instructions.
You are an SpR5 and are running the antenatal clinic –
your consultant is absent due to illness.
You are about to see Mary Hapsburg. She has been booked
by an experienced midwife who has done the relevant investigations and given
all the routine booking advice about healthy life-style, Down’s syndrome
screening, etc. All that is left is the advice about farming which she was not
comfortable about advising on – she has asked you to see Mary to do this.
The GP letter reads: “Please see Mary Hapsburg who is 25
years old. This is her first pregnancy and the gestation will be 10 weeks,
calculated from her LMP, by the time fs the appointment.
She is healthy and rubella-immune. She and her husband
are farmers and she wishes to know the
implications for her and her pregnancy. I don’t know much about this and leave
it to you to provide the expert advice”.
21. Viva.
Diathermy.
Suggested
structure of a MRCOG viva.
This
topic features regularly in the exam and is something you should know well as
it is a standard tool but with significant hazards. The viva covers the basics.
The TOG questions are a bit more technical but might be reproduced in the exam.
El-Sayed’s TOG article in 2020 makes it topical.
There
are other resources that you might find useful if you want more: they are on
the website.
Questions.
1. What is diathermy?
2. What kind of current is used:
AC, DC or other?
3. What frequency is used?
4. What are the tissue effects of
diathermy and what types of current are used to achieve them?
5. What are the differences between
bipolar and unipolar diathermy?
6. Risks of diathermy.
7. Discuss direct coupling.
8. Discuss capacitive coupling.
TOG questions.
These
are open
access, so reproduced here. Read the article:
El-Sayed
M et al: “Safe use of electrosurgery … in laparoscopic surgery”. TOG. 2020;22,1:9–20.
With regard
to the variables that influence electrosurgical tissue effects:
1.
reducing the active electrode surface area would significantly
increase the thermal effect without
increasing the power output.
2.
increasing tension on the tissue enhances coagulation but compromises
cutting.
With regard
to electrosurgical complications during laparoscopy:
3.
direct coupling is the most common type of complication.
4.
about half of unintended burns are recognised during surgery.
Insulation
failure in laparoscopic surgery:
5.
is associated with severe burns when the insulation defect is
microscopic.
6.
occurs more in robotic compared with laparoscopic instruments.
Concerning
antenna coupling:
7.
it is initiated in the surgical field.
8.
it is reduced by separating the laparoscopy tower from the
electrosurgical unit and avoiding close parallel arrangement of the cords.
Active
electrode monitoring technology:
9.
is used with monopolar and bipolar instruments.
10. eliminates burns caused
by insulation failure and capacitive coupling.
11. does not protect against
direct coupling.
With regard
to the use of electrosurgery in patients with cardiac implantable electronic
devices:
12. bipolar or ultrasonic
devices are recommended in patients highly dependent on the devices.
13. patients with an
implantable cardioverter defibrillator should deactivate it before surgery.
Electrosurgical
smoke:
14. contains carcinogenic
chemicals with few documented cases of cancer.
15. contains particles mostly
bigger than 5 µm.
With regard
to electrosurgery:
16. it is the application of
high‐frequency direct current.
17. cutting occurs when the
intracellular temperature rises to between 60°C and 95°C.
With regard
to power outputs:
18. the power setting should
be between 50 W and 80 W for effective cutting.
19. the setting should be
between 20 W and 30 W for effective coagulation.
In conventional
bipolar devices:
20. the two electrodes are
situated at the tip of the instrument.
22. Viva. Cochrane
review.
The examiner will ask 10 questions
about Cochrane.
22. EMQ. Folic
acid fortification of flour.
Folic acid fortification of
flour.
Abbreviations.
FFF: fortification of flour with
folic acid.
NTD: neural tube defect.
Scenario 1.
What is the incidence of NTD in the UK?
Scenario 2.
What is the risk of an affected sibling for the woman who becomes
pregnant after having a baby with NTD?
Scenario
3.
Which foods contain significant amounts of folic acid?
Scenario 4.
What percentage of folic acid is destroyed by cooking / food
storage?
Scenario 5.
How many people in the UK are estimated to have a folate-deficient
diet?
Scenario 6.
What is the significance of the MTHFR (Methylenetetrahydrofolate reductase gene)?
Scenario 7.
What is the significance of the Meckel-Gruber syndrome to this
issue?
Scenario 8.
By what gestation has the neural tube closed?
Scenario 9.
What proportion of pregnant women have taken folic acid
preconceptually?
Scenario 10.
What dose and duration of folic acid is advised for routine periconceptual
use?
Scenario 11.
List the women to whom a higher dose should be offered.
Scenario 12.
How effective is periconceptual folic acid consumption in reducing
NTD risk in the low-risk population?
Scenario 13.
How effective is periconceptual folic acid consumption in reducing
NTD risk in women who have had an affected baby?
Scenario 14.
What is the risk of NTD recurrence for a woman who has had two
affected babies?
Scenario 15.
What is the risk of NTD in Ireland?
Scenario 16. What is
the significance of the name “Bukowski” in relation to folic acid?
Scenario 17.
What effect does periconceptual folic acid have on the risk of
stillbirth?
Scenario 18.
What effect does periconceptual folic acid have on the risk of
autistic spectrum disorder?
Scenario 19.
What effect does periconceptual folic acid have on maternal
haemoglobin levels?
Scenario 20.
What recommendations have been made by the RCOG to improve folic
acid levels in pregnancy?
Scenario 21.
Which names are of importance in the history of folic acid and
NTD?
Scenario 22.
What neurological condition has been thought potentially
problematic with folic acid supplementation?
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