Vol 19 Issue 2 Flashcards
A 60-year-old woman has just been diagnosed with recurrent cervical cancer, which had been treated with radiotherapy. She is offered a pelvic exenteration. This surgery would be considered palliative rather than curative when she has…?
A - Central disease involving the bladder
B - Central disease involving the rectum
C - Disease involving the vagina and side wall
D - Disease that has spread to the bladder, urethra and side wall
E - Involvement of the pelvic and para-aortic nodes
Involvement of the pelvic and para-aortic nodes
Exenteration is considered palliative in the presence of distant metastases, peritoneal spread, positive pelvic and para-aortic nodes and incomplete histological resection (R1 or R2). This type of surgery is best performed for recurrent central disease involving the pelvic organs.
What is the best investigation to identify extrapelvic disease in patients being considered for pelvic exenteration for recurrent gynaecological cancer?
A - Abdominal x-ray
B - Computer tomography (CT) scan
C - Magnetic resonance imaging of the pelvis and abdomen
D - Positron emission tomography (PET)-CT scan
E - Ultrasound scan of the abdomen and pelvis
Positron emission tomography (PET)-CT scan
A PET-CT scan is useful in defining metastases.
A fluorodeoxyglucose PET scan has a sensitivity of 100% and a specificity of 73% in detecting extrapelvic disease and may be the most accurate radiological test to determine eligibility for pelvic exenteration.
A 33-year-old woman with a strong family history of mental illness has been referred by the community midwife at 32 weeks of gestation because of suspicion of a severe mental illness. What would be the advantage of raising awareness and normalising the need to access support in her management?
A - Allows the woman to have a better insight into her illness
B - Converts a mental problem into an acceptable medical problem that would be managed appropriately
C - Demystifies the danger and allows for management of the patient in the community
D - Enables caregivers to come closer to reducing a potentially life-threatening risk
E - Helps with acceptance of the need for urgent admission and treatment
Enables caregivers to come closer to reducing a potentially life-threatening risk
In crises management, raising awareness and normalising the need to access support helps caregivers to come closer to reducing the potentially life-threatening risks.
You have seen a 26-year-old primigravida at 36 weeks of gestation, and following consultation, your assessment of her mental health has led you to have concerns regarding the safety of the women and her baby. What would be the best approach to take in her management?
A - Admit her into a mother and baby unit
B - Commence antipsychiatric medication
C - Escalate to the duty psychiatric nurse or the liaison psychiatry nurse
D - Refer her to a social worker immediately
E - Section the patient under the Mental Health Act
Escalate to the duty psychiatric nurse or the liaison psychiatry nurse
If during consultation, you have concerns regarding the safety of a woman and/or her baby or the family, you must escalate this to the duty psychiatric nurse (within hours) or the liaison psychiatry nurse (out of hours).
A 24-year-old primigravida is booking for antenatal care at 10 weeks of gestation. She is otherwise healthy and has no past medical or family history of relevance. What is the current NICE recommendation with regard to the timing of screening for anaemia in pregnancy in this woman?
A - At booking and at 28 weeks of gestation
B - At booking and at 36 weeks of gestation
C - At booking and then at 28 and 36 weeks of gestation
D - At booking and then at every antenatal visit up to 36 weeks
E - At booking and then every 4 weeks until 36 weeks
At booking and at 28 weeks of gestation
NICE guideline on antenatal care advocate screening for anaemia at booking and at 28 weeks of gestation. During pregnancy, anaemia is best assessed using serum ferritin. Ferritin initially rises and then gradually falls as pregnancy advances so that by 32 weeks of gestation, levels are 50% less than pre-pregnancy levels. Treatment should be commenced when ferritin levels fall below 30 microgram/l.
A 20-year-old primigravida was placed on iron tablets after her booking bloods came back showing that she has iron-deficiency anaemia. Two weeks later a repeat blood test is performed and confirms that she is responding to the iron tablets. She continues with the iron tablets but has now had a full blood count and serum ferritin that are all normal. How long should be recommended that she continue with the iron tablets?
A - For another 1 month B - For another 3 months at least C - She can stop the iron tablets now D - Until the end of pregnancy E - Until the end of the puerperium
For another 3 months at least
Once haemoglobin and serum ferritin levels are normal, treatment should be continued for 3 months. If the haemoglobin falls below the normal level again investigations should be considered along with provision of iron supplementation
A 21-year-old woman is seen at her first antenatal visit at 8 weeks of gestation. She complains of breathlessness, palpitations and poor concentration. You examine and find that she is anaemic. A full blood count is performed and her haemoglobin comes back at 65 g/l. What would be the treatment for this patient?
A - Blood transfusion B - Combined parenteral and oral iron treatment C - Iron tablets – double dose D - Iron tablets – standard dose E - Parenteral iron
Blood transfusion
During pregnancy, the use of parenteral iron is contraindicated in the first trimester. In this patient, therefore, the best treatment option is blood transfusion. This is determined partly by the fact that she is symptomatic and has severe anaemia.
What is now generally considered an indication for performing a thrombophilia test in a woman who presents at 8 weeks of gestation for booking?
A - Previous pre-eclampsia
B - Previous small for gestational age baby
C - Previous stillbirth
D - Previous three miscarriages
E - When the result will be used to improve or modify management
When the result will be used to improve or modify management
Myers and Pavord stated that laboratory testing should only be performed whenever the results influence decisions on therapy or prevention. The 2016 Anticoagulation Forum in the USA guideline recommends that thrombophilia testing ‘should only be performed when the result will be used to improve or modify management’.
What is the estimated mortality risk associated with catastrophic antiphospholipid syndrome?
A -10% B - 20% C - 30% D - 40% E - 50%
Catastrophic antiphospholipid syndrome is a life-threatening disease conferring 50% risk of mortality. It complicates less than 1% of antiphospholipid syndrome (APS) cases and is characterised by the onset of rapidly progressive and widespread thrombotic microangiography and multiple organ failure.
What is the main advantage of drainage over ovarian cystectomy in the treatment of an ovarian endometrioma that measures 4 cm and is associated with dysmenorrhea and dyspareunia?
A - Ovarian reserve is less likely to be compromised
B - Recurrence is less
C - The procedure has less complications
D - The risk of adhesion formation is less
E - The risk of compromising future fertility is greater with drainage
Ovarian reserve is less likely to be compromised
Laparoscopic excision is superior to drainage and coagulation by bipolar diathermy for treating the recurrence of dysmenorrhea, dyspareunia and non-menstrual pain as well as reducing the rates of subsequent surgery. While the superiority of excision over drainage and coagulation/ablation might be expected, concerns about excessive resection of ovarian tissue compromising future fertility remain, with reported risk of ovarian failure after bilateral ovarian endometrioma cystectomy of the order of 2.4%.
A 38-year-old woman has been offered a total abdominal hysterectomy with preservation of the ovaries as treatment of her endometriosis-associated chronic pelvic pain. What is the main disadvantage of leaving her ovaries behind?
A - She has a greater risk of developing an endometrioma
B - She has a four-times greater risk of reoperation
C - She has a four-times risk of ovarian endometroid cancer
D - She has a six-fold greater risk of developing recurrent pain
E - She is at an increased risk of trapped ovary syndrome
She has a six-fold greater risk of developing recurrent pain
Ovarian conservation at hysterectomy presents a six-fold greater risk for the development of recurrent pain and an 8.1-times greater risk of re-operation.
What is the best predictor of cardiovascular risk in a 37-year-old woman who has been diagnosed with polycystic ovarian syndrome?
A - Her abdominal circumference B - Her blood pressure C - Her BMI D - Her LH levels E - Her waist circumference
Her waist circumference
An assessment of BMI alone is not considered a reliable predictor of cardiovascular risk. It has been suggested that rather than BMI itself, the distribution of fat is important, with android obesity a greater factors than gynaecoid obesity. Hence waist circumference, which is an indicator of abdominal visceral fat rather than subcutaneous fat is a valuable measurement.
An amenorrhoeic woman with polycystic ovarian syndrome was given norethisterone acetate (20 mg/day for 5 days) to induce a withdrawal bleed and following the withdrawal bleed was commenced on clomifene citrate 50 mg/day from D2. She has come back saying that she has not had a period after 35 days. What would be your next step in her management?
A - Pregnancy test and if negative, await bleed and increase clomifene citrate (CC) to 100 mg from D2
B - Pregnancy test and if negative commence on second dose of CC
C - Pregnancy test and if negative induce a withdrawal bleed with a progestogen and then initiate CC
D - Pregnancy test and if negative, recommend that she waits for a bleed before restarting the CC
E - Pregnancy test and if negative ultrasound scan and then advise to wait for a bleed before commencing the next course of CC
rrect answer:
Pregnancy test and if negative induce a withdrawal bleed with a progestogen and then initiate CC
Clomifene citrate (CC) therapy is usually commenced on days 25 of the menstrual cycle and given for 5 days. If a woman with PCOS has oligo/amenorrhoea, it is necessary to exclude pregnancy and then induce a withdrawal bleed using a short course of a progestogen such a medroxyprogesterone acetate 20 mg/day for 510 days. The starting dose of CC is 50 mg/day. If she has not menstruated by day 35 and is not pregnant, a progestogen-induced withdrawal bleed should be initiated. The CC dose may be increased if there is no response. Doses of 150 mg/day or more do not appear to be of benefit.
A 46-year-old woman underwent a subtotal hysterectomy as treatment for heavy menstrual bleeding. What percentage (approximate) of women who have had a subtotal hysterectomy will cyclical bleeding be a persistent symptom?
A - <3% B -5% C - 10% D - 15% E - 20%
5%
Subtotal hysterectomy is associated with a shortened operative time, lower intraoperative blood loss and a lower incidence of postoperative pyrexia or urinary retention compared to those who undergo a total hysterectomy. Approximately 5% of women who have had a subtotal hysterectomy have continuing cyclical light bleeding.
A hysterectomy was offered to a 37-year-old woman with heavy menstrual bleeding that was refractory to medical treatment. What would be the main advantage of a subtotal hysterectomy over a total hysterectomy?
A - Better sexual/orgasmic satisfaction B - Lower morbidity C - Reduced impact on ovarian function D - Reduced incidence of bladder dysfunction E - Surgical expertise is less
Lower morbidity
The benefits of subtotal hysterectomy over a total hysterectomy, especially if performed by minimal access surgery, include reduced morbidity, shorter hospital stay with recovery taking about 2 weeks, less bladder dissection and reduced haemorrhage associated with removal of the cervix. Randomised trials have failed to demonstrate any difference in sexual satisfaction.
