Volume 18 Issue 3 - July 2016 Flashcards
Robotic surgery is increasingly becoming important in gynaecological surgery. What is the main role of an assistant in robotic surgery?
Adjustment of the 3D vision Control of the camera Help manipulate the instruments Provide additional foot control at the console Undertake supplemental action
Undertake supplemental action
The answer is undertake supplemental action. In robotic surgery, the surgeon controls the instruments, camera and energy source remotely from hand and foot controls at the consoles. A bedside assistant is utilised for supplemental actions, such as suction, retraction and uterine manipulations.
What is the main advantage of robotic surgery over laparoscopic surgery?
Better precision and microsurgical dissection Decreased hospital stay Improved cosmesis Less pain after surgery Quicker recovery for the patient
Better precision and microsurgical dissection
The answer is better precision and microsurgical dissection. Compared with conventional laparoscopy, the robotic system downscales movements to up to 10 times, which provides tremor filtration and allows for precise movements. A stable camera with 3D vision further assists such precision and microsurgical dissection.
A 32-year-old woman who had a kidney transplant 18 months ago is now on maintenance doses of antirejection medication and a small dose of steroids. She wishes to start trying for a baby. What important factor at this stage will determine her risk from pregnancy?
Coexisting hypertension and proteinuria Glycosuria Superimposed diabetes Persistent anaemia Presence of infections
Coexisting hypertension and proteinuria
The answer is coexisting hypertension and proteinuria. The risk from pregnancy in women with a stable graft function at least 1 year after transplantation are dependent upon the level of the graft function and the presence of coexisting hypertension and proteinuria.
A 29-year-old transplant patient on mycophenolate mofetil wishes to become pregnant. She attends a preconception clinic run by the transplant and obstetric multidisciplinary team. She is advised to switch the mycophenolate mofetil to azathioprine. How long should she be on the new medication for before she becomes pregnant?
1 month 2 months 3 months 4 months 6 weeks
3 months
The answer is 3 months. Mycophenolate mofetil is teratogenic and it is therefore advisable for it to be switched to azathioprine, which is considered safe in pregnancy. A 3-month period following drug switch facilitates the recommended wash-out period for mycophenolate mofetil prior to pregnancy and allows confirmation of graft stability and can be used for prepregnancy administration of folic acid as well
A 30-year-old woman attends at 12 weeks for a nuchal translucency measurement as part screening for aneuploidy. What approximate detection rate for trisomy 21 using nuchal translucency alone will you quote to this woman?
77% 87% 80% 90% 93%
77%
The answer is 77%. Large prospective studies have demonstrated improvements in the detection rate for trisomy 21 from 77% for nuchal translucency (NT) alone (for a false-positive rate of 4.7%) to 85–90% for a combined first-trimester test using measurements of NT and the placental protein markers free β-hCG and pregnancy-associated plasma protein (PAPP-A) for a false-positive rate of approximately 5%.
A 33-year-old primigravida is seen for booking at 10 weeks of gestation. Following counselling she opts for the integrated test for aneuploidy. What is the main advantage of this test over the first-trimester screening test?
It has a better acceptance by patients It has a higher detection rate for aneuploidy It has a lower false-positive rate It is less time-consuming It is more cost-effective
It has a lower false-positive rate
The answer is it has a lower false-positive rate. The Health Technology Assessment of Antenatal Screening for Down’s syndrome (published in 2003) showed that an integrated test utilising first- and second-trimester measurements offered the best overall performance (false-positive rate of 1.2% for a detection rate of 85%) compared with a detection rate of 85–90% for the first-trimester combined biochemical and nuchal translucency screening for a false-positive rate of 5.7%. Acceptance of the integrated test is lower and it’s more costly than the first-trimester combined test.
A 50-year-old woman has had debulking surgery for ovarian cancer. What standard adjuvant treatment would be recommended for this patient?
A combination of platinum for six cycles and radiotherapy
Paclitaxel and carboplatin for six cycles
Paclitaxel and carboplatin for three cycles
Paclitaxel and carboplatin for six cycles and radiotherapy
Paclitaxel and carboplatin for three cycles and radiotherapy
Paclitaxel and carboplatin for six cycles
The answer is paclitaxel and carboplatin for six cycles. Surgery remains the primary treatment of ovarian cancer. However, following primary surgery, the conventional approach has been to use six cycles of standard carboplatin and paclitaxel at 3-weekly intervals. Alternatives are emerging but this remains the standard adjuvant chemotherapy. Radiotherapy is not considered the standard adjuvant therapy.
A 57-year-old woman presents with a bloody vaginal discharge of 5 months’ duration. Her last cervical smear was 2 years ago and was normal. She has had two normal vaginal deliveries and used the combined oral contraceptive pill for 10 years after her last delivery 27 years ago. She is examined and found to have a growth on the cervix that appears to extend to involve half of the vagina. The side wall is involved with disease. An ultrasound scan of the abdomen shows a left hydroureter and mild left hydronephrosis. A biopsy has confirmed this to be cervical carcinoma. What will be the best treatment for this patient?
Chemotherapy with carboplatin and paclitaxel
Cisplatin and pelvic irradiation
Neo-adjuvant chemotherapy followed by Wertheim’s hysterectomy
Radiotherapy
Wertheim’s hysterectomy
Cisplatin and pelvic irradiation
The answer is cisplatin and pelvic irradiation. The primary treatment of cervical cancer is surgery when it is in the early stages. However, for disease that has spread beyond stage IIA the current consensus is for weekly cisplatin in combination with pelvic radiation. This is now considered the gold standard of care. Neoadjuvant chemotherapy (NACT) followed by surgery has been suggested as effective in those with bulky disease but the evidence is still emerging.
A 34-year-old woman with Type 1 diabetes is 7 weeks pregnant in her first pregnancy. What will be an indication for placing her on an insulin pump?
She has a high HbA1c that needs to be reduced early enough to prevent an increased risk of congenital malformations
She is suffering from hyperemesis gravidarum
She is able to achieve adequate blood glucose control with multiple daily injections but is experiencing occasional significant disabling hypoglycaemia
She needs high doses of rapidly acting insulin
She suffers from the “dawn phenomenon” (i.e. requiring an increased dose of insulin for a short time in the early morning)
She suffers from the “dawn phenomenon” (i.e. requiring an increased dose of insulin for a short time in the early morning)
The answer is she suffers from the “dawn phenomenon” (i.e. requiring an increased dose of insulin for a short time in the early morning). Expert opinion indicates that pumps ameliorate care particularly in individuals who have inadequately controlled diabetes, those who suffer with recurrent hypoglycaemia or the “dawn phenomenon” (requiring an increased dose of insulin for a short time in the early morning” and those who need only a very small daily insulin requirement.
A 28-year-old woman with type I diabetes attends the pre-conception clinic and is found to be struggling to control her diabetes. Her insulin requirements are not high. A decision is taken to commence her on an insulin pump in order to get her glycaemic control better before pregnancy. What would be the minimum interval from commencing the pump to her starting to try for a pregnancy?
4 weeks 6 weeks 8 weeks (2 months) 12 weeks (3 months) 16 weeks (4 months)
12 weeks (3 months) The answer is 12 weeks (3 months). Pump use in pregnancy is most successful with a motivated receiver and the involvement of a multidisciplinary team that includes a diabetologist, an obstetrician, specialised diabetes nurse, a midwife and a dietician. When switching to a pump prior to pregnancy, most specialists would advocate pump use for at least 3 months before attempting to conceive in order to achieve stable blood glucose levels and become adept at using the pump. However, it is possible to start a pump during pregnancy if needed.
A 30-year-old woman who suffers from inflammatory bowel disease (IBD), which has been active, reports that she is pregnant. She is currently taking sulfasalazine therapy. What is the likely course of the IBD in the pregnancy?
It is likely to become more active during pregnancy
It is likely to remain active
It is likely to respond better to treatment than outside pregnancy
There is a higher chance of remission
The course tends to be fluctuating between remission and active disease
It is likely to remain active
The answer is it is likely to remain active. Women with disease in remission at the time of conception are more likely to have a normal pregnancy. The risk of relapse during pregnancy in this stable cohort is approximately 30% which is similar to that in the non-pregnant patient. A recent meta-analysis showed that women who had active IBD at the time of conception had a two-fold increase in having an active disease during pregnancy. Pregnant women with active disease are therefore more likely to have active disease both during pregnancy and 6 months postpartum.
A 31-year-old woman who has been receiving treatment for inflammatory bowel disease (IBD) is now 34 weeks pregnant. Her IBD has been in remission since she was placed on 30 mg prednisolone daily. What precaution must be taken when she goes into labour?
Administer intravenous hydrocortisone in labour
Administer intravenous hydrocortisone during and immediately after delivery
Increase dose of prednisolone after delivery
Maintain her on 30 mg per day
Stop prednisolone
Administer intravenous hydrocortisone during and immediately after delivery
The answer is administer intravenous hydrocortisone during and immediately after delivery. Pregnant women on steroids (prednisolone equivalence of greater than 5 mg per day) for more than 4 weeks before giving birth will need additional oral doses or parenteral hydrocortisone during delivery and in the immediate postpartum period to lower the risk of acute adrenal crises.
A 50-year-old woman is seen in the gynaecology clinic with urinary symptoms of frequency, urgency, urge incontinence and nocturia. She has had three normal vaginal deliveries and does not have any features of prolapse. A urodynamic assessment is arranged and lifestyle changes are introduced. This has confirmed detrusor overactivity. The lifestyle changes instituted have made no difference to her symptoms after 6 months, hence a decision has been taken to offer her an antimuscarinic. What will be a contraindication to starting her on such a medication?
Crohn’s disease Hypertension on treatment with an angiotensin-converting-enzyme inhibitor Irritable bowel syndrome Myasthenia gravis Severe asthma
Myasthenia gravis
The answer is myasthenia gravis. Antimuscarinic agents act by blocking muscarinic receptors in the bladder smooth muscle leading to a direct relaxant effect. Common side effects include a dry mouth, constipation and dry eyes resulting from blockage of these receptors are other sites. These drugs are contraindicated in cases of myasthenia gravis, ulcerative colitis, toxic megacolon and where there is gastrointestinal or bladder obstruction or atony.
A 65-year-old woman has been assessed and offered botilinum toxin for the treatment of her refractory overactive bladder. What must she be trained to do before this treatment can be started?
Accurately keep a voiding diary
Learn to tolerate the minor side effects of this treatment
Reduce her fluid intake including caffeine
Undertake intermittent self-catheterisation
Undertake regular pelvic floor exercises
Undertake intermittent self-catheterisation
The answer is undertake intermittent self-catheterisation. NICE guidance advices that all women who are schedule to undergo treatment with botulinum toxin must be trained in intermittent self-catheterisation before the treatment, but the cost-effectiveness of this has been questionable. This is primarily because only 10–15% of women on this treatment will actually need to perform intermittent self-catheterisation.
