- Email: [email protected]
Self assessment questions
SELF-ASSESSMENT
Self assessment questions Question 1 (EMQ)
contraception. She is not sure she has completed her family, although her endocrine physician has expressed their concerns about another pregnancy because of her retinopathy and early renal disease. What is the best option, from the choices below, for contraception for this woman? (A) Encourage sterilization (B) Combined oral contraceptive use (C) Copper IUD (D) LNG-IUS (E) DMPA
Below are listed the risk categories published by the UK faculty of sexual and reproductive healthcare for the use of contraceptives in certain medical conditions. From this list, pick the correct category for the contraception-medical condition pairings described in question stems (i)e(xi). (A) Category 1 (B) Category 2 (C) Category 3 (D) Category 4 (i) COCP (combined oral contraceptive pill) use in well controlled hypertension (ii) DMPA (Depot medroxyprogesterone acetate) use in a Factor V Leiden heterozygote (iii) POP (Progesterone only pill) use in an insulin dependent diabetic with vascular disease (iv) Use of the Cu-IUCD in someone being treated for a DVT (v) Use of the LNG-IUD (Mirena) in someone with diabetic retinopathy (vi) DMPA use with hypertensive vascular disease (vii) COCP use in mild hypertension (150/94) (viii) COCP use in someone with history of gestational diabetes mellitus (ix) COCP use in someone with varicose vein (x) DMPA use in adequately controlled hypertension (xi) Implanon use in severe hypertension
Question 4 Answer true or false With regard to the risks of caesarean section: (A) The risk of bladder injury during CS is 1% (B) The risk of fetal laceration is 1e2% (C) The likelihood of complications during an elective CS is approximately the same as during an emergency CS performed in early labour (D) The risk of hysterectomy during CS in a patient with a morbidly adherent placenta is 25% (E) It is perfectly reasonable to perform sterilization at the time of an emergency CS
Question 5 (SBA) A primip is induced for suspected fetal growth restriction with prostaglandins. The symphysiofundal height is only 33 cm at 38 weeks gestation and a series of scans suggest crossing of the abdominal circumference centiles, although liquor volume and umbilical artery Doppler recordings are in the normal range. Her membranes are ruptured artificially at 2 cm dilatation and Syntocinon started. Within an hour she is contracting regularly 3e4 every 10 minutes and a further examination 3 hours after this shows she is 3 cm dilated. A further 3 hours later you are asked to review the situation because the midwife has concerns about the CTG. You find a baseline rate of 155 bpm (previously 135 bpm), variability of <5 bpm for 50 minutes and typical variable decelerations for the last 2 hours, occurring with the majority of the contractions. On examination, you find her to be 4 cm dilated with a 1 cm thick cervix and meconium stained liquor. She has ketonuria and is requesting more pain relief, having so far received codeine. Which of the following options would be the most appropriate course of action? (A) Turn to left lateral, rehydrate, give facial oxygen and reassess in 1 hour (B) Proceed to category 2 caesarean section (C) Perform a fetal blood sampling (D) Proceed to category 1 caesarean section under general anaesthesia
Question 2 Answer true or false Regarding contraceptive use in women with breast conditions: (A) Hormonal contraception is contraindicated in women with current or recent breast cancer (UK category 4). (B) Hormonal contraception is contraindicated in women with a positive family history of breast cancer. (C) The Women’s CARE study found increased risk of breast cancer to be associated with use of DMPA. (D) Oral hormonal contraceptive use reduces ovarian cancer risk in BRCA1 and BRCA2 carriers. (E) (LNG-IUS: Mirena) may reduce the risk of endometrial abnormalities during tamoxifen therapy.
Question 3(SBA) A 35-year-old married multiparous patient with long standing type 1 diabetes seeks advice regarding
Alec McEwan MRCOG is a Consultant in Fetal and Maternal Medicine at the Division of Obstetrics and Gynaecology, Queen’s Medical Centre, Nottingham, UK. Conflicts of interest: none.
OBSTETRICS, GYNAECOLOGY AND REPRODUCTIVE MEDICINE 24:2
65
Ó 2014 Elsevier Ltd. All rights reserved.
SELF-ASSESSMENT
Answer 4 (A) False (B) True (C) True (D) True (E) True The risk of bladder injury is rare at 1 per 1000. The risk of complications during an elective procedure is 16 per 100, whereas during early labour it is 17 per 100. Performing a sterilization will depend on the circumstances. If it has been discussed antenatally and the reason for emergency CS is failure to progress with no fetal concerns, it would still be reasonable to perform a sterilization.
(E) Turn off the Syntocinon, give terbutaline and recommend an epidural
Answers Answer 1 (i) C (cat 3) (ii) B (cat 2) (iii) B (cat 2) (iv) A (cat 1) (v) B (cat 2) (vi) C (cat 3) (vii) C (cat 3) (viii) A (cat 1) (ix) A (cat 1) (x) B (cat 2) (xi) A (cat 1)
Answer 5 The single best answer is (B) proceed to category 2 caesarean section. This is a labour with risk factors (fetal growth restriction and meconium) for fetal compromise. At the point of your CTG review, it is pathological. There are two nonreassuring features (reduced variability for 50 minutes and typical variable decelerations with over 50% contractions occurring for more than 90 minutes) so it should be classified as pathological. It is entirely appropriate to resuscitate the fetus by changing maternal position, turning off Syntocinon, possibly giving maternal facial oxygen and even giving terbutaline, but this would be insufficient and further action is indicated. If the CTG is pathological, then either delivery of the baby, or more sensitive assessment of the fetal condition (ie fetal blood sampling) is required. Although FBS might be possible here, it would not be safe to site an epidural first, during which time a possibly already compromised fetus might deteriorate further. Furthermore, when taken in the whole context of the labour, the pathological CTG early on in this high risk labour is better responded to by delivery of the baby by caesarean section. The fetal pH may be normal at this point, but is there a realistic prospect of reaching full dilatation and effecting a safe vaginal birth? Probably not. Progress is not particularly good, and the cervix is not even fully effaced. When categorizing the caesarean section one should consider if there is immediate threat to the life of mother or baby. A ‘fast category 2’ would be appropriate. Demanding a general anaesthetic would be unnecessary and an attempt at regional anaesthesia would be appropriate.
Answer 2 (A) True (B) False (C) False (D) True (E) True The Women’s Contraceptive and Reproductive Experiences (CARE) study recently found no increase in the risk of breast cancer in users of oral hormonal contraception, or those receiving DMPA. These options are not contraindicated for women with a family history of breast cancer, or even BRCA1 and 2 mutation carriers where the COCP actually reduces the risk of ovarian malignancy. The LNGIUS may reduce the risk of endometrial abnormalities in women receiving tamoxifen for breast cancer treatment, however it remains somewhat unclear whether this carries a higher recurrence risk for the breast cancer itself. Answer 3 The single best answer is (C) a copper IUD. Although this woman should receive careful prepregnancy counselling, it would be unreasonable to encourage sterilization when she has expressed a desire for another pregnancy. Copper intrauterine devices should be considered the first choice for contraception in diabetic women with underlying vascular or renal complications and in this group of women, the COCP and DMPA should be avoided (UK category 3). The LNG-IUS is considered category 2 and would be an alternative option if the copper IUD was associated with heavier bleeding or painful periods.
OBSTETRICS, GYNAECOLOGY AND REPRODUCTIVE MEDICINE 24:2
66
Ó 2014 Elsevier Ltd. All rights reserved.
Self assessment questions Question 1 (EMQ)
contraception. She is not sure she has completed her family, although her endocrine physician has expressed their concerns about another pregnancy because of her retinopathy and early renal disease. What is the best option, from the choices below, for contraception for this woman? (A) Encourage sterilization (B) Combined oral contraceptive use (C) Copper IUD (D) LNG-IUS (E) DMPA
Below are listed the risk categories published by the UK faculty of sexual and reproductive healthcare for the use of contraceptives in certain medical conditions. From this list, pick the correct category for the contraception-medical condition pairings described in question stems (i)e(xi). (A) Category 1 (B) Category 2 (C) Category 3 (D) Category 4 (i) COCP (combined oral contraceptive pill) use in well controlled hypertension (ii) DMPA (Depot medroxyprogesterone acetate) use in a Factor V Leiden heterozygote (iii) POP (Progesterone only pill) use in an insulin dependent diabetic with vascular disease (iv) Use of the Cu-IUCD in someone being treated for a DVT (v) Use of the LNG-IUD (Mirena) in someone with diabetic retinopathy (vi) DMPA use with hypertensive vascular disease (vii) COCP use in mild hypertension (150/94) (viii) COCP use in someone with history of gestational diabetes mellitus (ix) COCP use in someone with varicose vein (x) DMPA use in adequately controlled hypertension (xi) Implanon use in severe hypertension
Question 4 Answer true or false With regard to the risks of caesarean section: (A) The risk of bladder injury during CS is 1% (B) The risk of fetal laceration is 1e2% (C) The likelihood of complications during an elective CS is approximately the same as during an emergency CS performed in early labour (D) The risk of hysterectomy during CS in a patient with a morbidly adherent placenta is 25% (E) It is perfectly reasonable to perform sterilization at the time of an emergency CS
Question 5 (SBA) A primip is induced for suspected fetal growth restriction with prostaglandins. The symphysiofundal height is only 33 cm at 38 weeks gestation and a series of scans suggest crossing of the abdominal circumference centiles, although liquor volume and umbilical artery Doppler recordings are in the normal range. Her membranes are ruptured artificially at 2 cm dilatation and Syntocinon started. Within an hour she is contracting regularly 3e4 every 10 minutes and a further examination 3 hours after this shows she is 3 cm dilated. A further 3 hours later you are asked to review the situation because the midwife has concerns about the CTG. You find a baseline rate of 155 bpm (previously 135 bpm), variability of <5 bpm for 50 minutes and typical variable decelerations for the last 2 hours, occurring with the majority of the contractions. On examination, you find her to be 4 cm dilated with a 1 cm thick cervix and meconium stained liquor. She has ketonuria and is requesting more pain relief, having so far received codeine. Which of the following options would be the most appropriate course of action? (A) Turn to left lateral, rehydrate, give facial oxygen and reassess in 1 hour (B) Proceed to category 2 caesarean section (C) Perform a fetal blood sampling (D) Proceed to category 1 caesarean section under general anaesthesia
Question 2 Answer true or false Regarding contraceptive use in women with breast conditions: (A) Hormonal contraception is contraindicated in women with current or recent breast cancer (UK category 4). (B) Hormonal contraception is contraindicated in women with a positive family history of breast cancer. (C) The Women’s CARE study found increased risk of breast cancer to be associated with use of DMPA. (D) Oral hormonal contraceptive use reduces ovarian cancer risk in BRCA1 and BRCA2 carriers. (E) (LNG-IUS: Mirena) may reduce the risk of endometrial abnormalities during tamoxifen therapy.
Question 3(SBA) A 35-year-old married multiparous patient with long standing type 1 diabetes seeks advice regarding
Alec McEwan MRCOG is a Consultant in Fetal and Maternal Medicine at the Division of Obstetrics and Gynaecology, Queen’s Medical Centre, Nottingham, UK. Conflicts of interest: none.
OBSTETRICS, GYNAECOLOGY AND REPRODUCTIVE MEDICINE 24:2
65
Ó 2014 Elsevier Ltd. All rights reserved.
SELF-ASSESSMENT
Answer 4 (A) False (B) True (C) True (D) True (E) True The risk of bladder injury is rare at 1 per 1000. The risk of complications during an elective procedure is 16 per 100, whereas during early labour it is 17 per 100. Performing a sterilization will depend on the circumstances. If it has been discussed antenatally and the reason for emergency CS is failure to progress with no fetal concerns, it would still be reasonable to perform a sterilization.
(E) Turn off the Syntocinon, give terbutaline and recommend an epidural
Answers Answer 1 (i) C (cat 3) (ii) B (cat 2) (iii) B (cat 2) (iv) A (cat 1) (v) B (cat 2) (vi) C (cat 3) (vii) C (cat 3) (viii) A (cat 1) (ix) A (cat 1) (x) B (cat 2) (xi) A (cat 1)
Answer 5 The single best answer is (B) proceed to category 2 caesarean section. This is a labour with risk factors (fetal growth restriction and meconium) for fetal compromise. At the point of your CTG review, it is pathological. There are two nonreassuring features (reduced variability for 50 minutes and typical variable decelerations with over 50% contractions occurring for more than 90 minutes) so it should be classified as pathological. It is entirely appropriate to resuscitate the fetus by changing maternal position, turning off Syntocinon, possibly giving maternal facial oxygen and even giving terbutaline, but this would be insufficient and further action is indicated. If the CTG is pathological, then either delivery of the baby, or more sensitive assessment of the fetal condition (ie fetal blood sampling) is required. Although FBS might be possible here, it would not be safe to site an epidural first, during which time a possibly already compromised fetus might deteriorate further. Furthermore, when taken in the whole context of the labour, the pathological CTG early on in this high risk labour is better responded to by delivery of the baby by caesarean section. The fetal pH may be normal at this point, but is there a realistic prospect of reaching full dilatation and effecting a safe vaginal birth? Probably not. Progress is not particularly good, and the cervix is not even fully effaced. When categorizing the caesarean section one should consider if there is immediate threat to the life of mother or baby. A ‘fast category 2’ would be appropriate. Demanding a general anaesthetic would be unnecessary and an attempt at regional anaesthesia would be appropriate.
Answer 2 (A) True (B) False (C) False (D) True (E) True The Women’s Contraceptive and Reproductive Experiences (CARE) study recently found no increase in the risk of breast cancer in users of oral hormonal contraception, or those receiving DMPA. These options are not contraindicated for women with a family history of breast cancer, or even BRCA1 and 2 mutation carriers where the COCP actually reduces the risk of ovarian malignancy. The LNGIUS may reduce the risk of endometrial abnormalities in women receiving tamoxifen for breast cancer treatment, however it remains somewhat unclear whether this carries a higher recurrence risk for the breast cancer itself. Answer 3 The single best answer is (C) a copper IUD. Although this woman should receive careful prepregnancy counselling, it would be unreasonable to encourage sterilization when she has expressed a desire for another pregnancy. Copper intrauterine devices should be considered the first choice for contraception in diabetic women with underlying vascular or renal complications and in this group of women, the COCP and DMPA should be avoided (UK category 3). The LNG-IUS is considered category 2 and would be an alternative option if the copper IUD was associated with heavier bleeding or painful periods.
OBSTETRICS, GYNAECOLOGY AND REPRODUCTIVE MEDICINE 24:2
66
Ó 2014 Elsevier Ltd. All rights reserved.